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Wang C, Qiu J, Huang X, Xu J, Pan L. Hemophagocytic lymphohistiocytosis secondary to rifampin treatment: A case report. Medicine (Baltimore) 2024; 103:e39011. [PMID: 39029059 PMCID: PMC11398768 DOI: 10.1097/md.0000000000039011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening systemic inflammatory syndrome characterized by an overactive immune response. This hyperactivation can arise from genetic mutations, infections, malignancies, or autoimmune disorders. Medication-induced HLH is extremely rare and requires special attention. PATIENT CONCERNS A 53-year-old female diagnosed with pulmonary and urinary tract tuberculosis. She underwent quadruple therapy, including isoniazid, rifampin, ethambutol, and pyrazinamide. Subsequently, she developed fever, hepatosplenomegaly, pancytopenia, hypertriglyceridemia, hypofibrinogenemia, hyperferritinemia, increased soluble CD25 levels, decreased natural killer cell activity, and hemophagocytosis, notably without eosinophilia. Her clinical symptoms were exacerbated by rifampin intake. DIAGNOSES Pulmonary and left kidney tuberculosis, multiple organ failure, and rifampin-induced HLH. INTERVENTIONS Anti-tuberculosis regimen (isoniazid, pyrazinamide, ethambutol, and levofloxacin, excluding rifampin) combined with glucocorticoid therapy. OUTCOMES Satisfactory recovery with improved clinical symptoms, laboratory tests, and chest imaging studies. LESSONS Early correct diagnosis and appropriate management of HLH are essential to save the lives of affected patients. The potential severe side effects of rifampin should not be ignored.
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Affiliation(s)
- Caihong Wang
- Tuberculosis Intensive Care Unit, Zhejiang Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang, China
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2
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Selvaratnam K, Nusair M, Mayurathan P. Overcoming Diagnostic Challenges: A Rare Presentation of Primary Hemophagocytic Lymphohistiocytosis (HLH) in a Young Female and the Importance of Timely Recognition. Cureus 2024; 16:e60242. [PMID: 38872699 PMCID: PMC11169998 DOI: 10.7759/cureus.60242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe life-threatening hematological disorder characterized by the dysregulation of the immune system and a hyperinflammatory response. Prompt treatment is crucial to prevent fatality. Although primarily affecting infants, HLH can also occur in children and adults. It is classified as primary and secondary, with primary HLH being genetic and predominantly affecting children. Secondary HLH is triggered by infections, malignancy, metabolic disorders, and rheumatological conditions. Diagnosis is based on the HLH-2004 criteria, considering clinical and laboratory parameters. Early diagnosis and treatment improve prognosis. Treatment follows the HLH-94 and HLH-2004 protocol and consists of eight weeks of induction therapy with cyclosporine, corticosteroids, and etoposide. This case describes a 26-year-old female diagnosed with HLH and successfully treated according to the protocol. The patient exhibited improvement and was discharged, demonstrating the importance of early diagnosis and appropriate management in adult HLH cases.
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Affiliation(s)
| | - Msm Nusair
- Internal Medicine Department, Teaching Hospital Batticaloa, Batticaloa, LKA
| | - Pakkiyaretnam Mayurathan
- University Medical Unit, Teaching Hospital Batticaloa, Batticaloa, LKA
- Clinical Sciences Department, Faculty of Health-Care Sciences, Eastern University Sri Lanka, Batticaloa, LKA
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Holloway A, Ahmed S, Manson JJ. Does your unwell patient have haemophagocytic lymphohistiocytosis? Br J Hosp Med (Lond) 2024; 85:1-12. [PMID: 38557089 DOI: 10.12968/hmed.2023.0394] [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: 04/04/2024]
Abstract
Haemophagocytic lymphohistiocytosis is a severe systemic hyperinflammatory syndrome characterised by dysregulation of immune cells and excessive production of cytokines, also known as a cytokine storm. It has distinctive clinical features with fever, hyperferritinaemia and falling blood counts. In adults, this usually occurs secondary to an underlying driver or trigger including infection, malignancy or rheumatic diseases. Prompt treatment with immunomodulatory therapy, including corticosteroids and the recombinant IL-1 receptor antagonist anakinra, is recommended to switch off the cytokine storm. Etoposide-based regimens are sometimes needed, and newer therapies such as emapalumab and JAK inhibitors are increasingly being used. The incidence of haemophagocytic lymphohistiocytosis has increased significantly over the last 20 years which may partly reflect increased awareness of the condition. Although relatively rare, haemophagocytic lymphohistiocytosis can be encountered by a broad range of hospital physicians, so knowing how to diagnose and treat this condition is essential. This article reviews the pathogenesis, clinical features, causes, diagnosis and treatment of haemophagocytic lymphohistiocytosis to improve physician recognition and management of this condition to improve future patient outcomes.
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Affiliation(s)
- Amelia Holloway
- Department of Rheumatology, Kings College Hospital, London, UK
| | - Saad Ahmed
- Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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Kawata K, Shima H, Shinjoh M, Yamazaki F, Kurosawa T, Yaginuma M, Takada H, Shimada H. Pneumocystis jirovecii pneumonia after CD4+ T-cell recovery subsequent to CD19-targeted chimeric antigen receptor T-cell therapy: A case report and brief review of literature. Cancer Rep (Hoboken) 2023; 6:e1885. [PMID: 37563749 PMCID: PMC10598253 DOI: 10.1002/cnr2.1885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND CD19-targeted chimeric antigen receptor (CAR)-T cell therapy involves administration of patient-derived T cells that target B cells, resulting in B-cell depletion and aplasia. In immunity against Pneumocystis jirovecii (Pj), CD4+ T cells and, more recently, B cells, are generally considered important. Antigen presentation by B cells to CD4+ T cells is particularly important. Trimethoprim-sulfamethoxazole (TMP/SMX) for Pj pneumonia (PJP) prophylaxis is generally discontinued when the CD4+ T-cell count is >200/μL. Here we report the first case, to our knowledge, of PJP in a patient with a CD4+ T cell count of >200/μL after CAR-T cell therapy. CASE A 14-year-old girl developed hemophagocytic lymphohistiocytosis (HLH) after cord blood transplantation (CBT) for relapsed precursor B-cell acute lymphoblastic leukemia (B-ALL). Twenty-one months after CBT, she was diagnosed with combined second relapse in the bone marrow and central nervous system. The patient was treated with CD19-targeted CAR-T cell therapy for the relapse. After CAR-T cell therapy, the patient remained in remission and continued to receive TMP/SMX for PJP prophylaxis. Seven months after CAR-T cell therapy, CD4+ T cells recovered and TMP/SMX was discontinued. The B-cell aplasia persisted. Ten months after CAR-T cell therapy, the patient developed PJP. The patient was also considered to have macrophage hyperactivation at the onset of PJP. Treatment with immunoglobulin, TMP/SMX, and prednisolone was initiated, and the patient's symptoms rapidly ameliorated. CONCLUSION The patient in the present case developed PJP despite a CD4+ T-cell count of >200/μL after CAR-T cell therapy, probably because of inadequate CD4+ T-cell activation caused by B-cell depletion after CAR-T cell therapy and repeated abnormal macrophage immune responses after CBT. It is important to determine the duration of TMP/SMX for prophylaxis after CAR-T cell therapy according to each case, as well as the CD4+ T-cell count.
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Affiliation(s)
- Kento Kawata
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Haruko Shima
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Masayoshi Shinjoh
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Fumito Yamazaki
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Takumi Kurosawa
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Mizuki Yaginuma
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Hiroshi Takada
- Department of PediatricsKeio University School of MedicineTokyoJapan
| | - Hiroyuki Shimada
- Department of PediatricsKeio University School of MedicineTokyoJapan
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Vashisht A, Ahluwalia P, Mondal AK, Singh H, Sahajpal NS, Fulzele S, Kota V, Gahlay GK, Kolhe R. Immune Factors Drive Expression of SARS-CoV-2 Receptor Genes Amid Sexual Disparity. Viruses 2023; 15:v15030657. [PMID: 36992366 PMCID: PMC10056434 DOI: 10.3390/v15030657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
The emergence of COVID-19 has led to significant morbidity and mortality, with around seven million deaths worldwide as of February 2023. There are several risk factors such as age and sex that are associated with the development of severe symptoms due to COVID-19. There have been limited studies that have explored the role of sex differences in SARS-CoV-2 infection. As a result, there is an urgent need to identify molecular features associated with sex and COVID-19 pathogenesis to develop more effective interventions to combat the ongoing pandemic. To address this gap, we explored sex-specific molecular factors in both mouse and human datasets. The host immune targets such as TLR7, IRF7, IRF5, and IL6, which are involved in the immune response against viral infections, and the sex-specific targets such as AR and ESSR were taken to investigate any possible link with the SARS-CoV-2 host receptors ACE2 and TMPRSS2. For the mouse analysis, a single-cell RNA sequencing dataset was used, while bulk RNA-Seq datasets were used to analyze the human clinical data. Additional databases such as the Database of Transcription Start Sites (DBTS), STRING-DB, and the Swiss Regulon Portal were used for further analysis. We identified a 6-gene signature that showed differential expression in males and females. Additionally, this gene signature showed potential prognostic utility by differentiating ICU patients from non-ICU patients due to COVID-19. Our study highlights the importance of assessing sex differences in SARS-CoV-2 infection, which can assist in the optimal treatment and better vaccination strategies.
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Affiliation(s)
- Ashutosh Vashisht
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar 143005, India
| | - Pankaj Ahluwalia
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Ashis K. Mondal
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Harmanpreet Singh
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | | | - Sadanand Fulzele
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Vamsi Kota
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Gagandeep K. Gahlay
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar 143005, India
- Correspondence: (G.K.G.); (R.K.)
| | - Ravindra Kolhe
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- Correspondence: (G.K.G.); (R.K.)
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Yadav G, Malhotra H, Mehta P, Sachu R, Rizvi I, Bharti VR, Kumar M, Kumar N, Ali W, Verma SP, Puri B, Dandu H. Severe COVID-19-associated hyperinflammatory syndrome versus classic hemophagocytic lymphohistiocytosis: similarities, differences, and the way forward. J Investig Med 2023; 71:244-253. [PMID: 36803041 PMCID: PMC9939916 DOI: 10.1177/10815589221140596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The hyperinflammatory immune response in severe COVID-19 infection shares features with secondary hemophagocytic lymphohistiocytosis (sHLH) in the form of fever, cytopenia, elevated inflammatory markers, and high mortality. There are contrasting opinions regarding utility of HLH 2004 or HScore in the diagnosis of severe COVID-19-related hyperinflammatory syndrome (COVID-HIS). This was a retrospective study of 47 patients of severe COVID-19 infection, suspected to have COVID-HIS and 22 patients of sHLH to other illnesses, to evaluate the diagnostic utility and limitations of HLH 2004 and/or HScore in context to COVID-HIS and to also evaluate the utility of Temple criteria for predicting severity and outcome in COVID-HIS. Clinical findings, hematological, and biochemical parameters along with the predictor of mortality were compared between two groups. Only 6.4% (3/47) of cases fulfilled ≥5/8 HLH 2004 criteria and only 40.52% (19/47) of patients showed HScore >169 in COVID-HIS group. 65.9% (31/47) satisfied the Temple criteria in COVID-HIS as compared with 40.9% (9/22) in the non-COVID group (p = 0.04). Serum ferritin (p = 0.02), lactate dehydrogenase (p = 0.02), direct bilirubin (p = 0.02), and C-reactive protein (p = 0.03) were associated with mortality in COVID-HIS. Both HScore and HLH-2004 criteria perform poorly for identifying COVID-HIS. Presence of bone marrow hemophagocytosis may help to identify about one-third of COVID-HIS missed by the Temple Criteria.
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Affiliation(s)
- Geeta Yadav
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Hardeep Malhotra
- Department of Neurology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Pankti Mehta
- Department of Rheumatology, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Ruovinuo Sachu
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Imran Rizvi
- Department of Neurology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Vipin Raj Bharti
- Department of Internal Medicine, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Manish Kumar
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Neeraj Kumar
- Department of Neurology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Wahid Ali
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Shailendra Prasad Verma
- Department of Clinical Hematology, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Bipin Puri
- Department of Pediatric Surgery, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Himanshu Dandu
- Department of Internal Medicine, King
George’s Medical University, Lucknow, Uttar Pradesh, India,Himanshu Dandu, Department of Internal
Medicine, King George’s Medical University, Chowk, Lucknow, Uttar Pradesh
226003, India.
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7
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Chevalier K, Schmidt J, Coppo P, Galicier L, Noël N, Lambotte O. Hemophagocytic Lymphohistiocytosis Associated With Cytomegalovirus Infection: 5 Cases and a Systematic Review of the Literature. Clin Infect Dis 2023; 76:351-358. [PMID: 35974465 DOI: 10.1093/cid/ciac649] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/30/2022] [Accepted: 08/09/2022] [Indexed: 01/18/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by an uncontrolled, persistent, hyperimmune response. It can be triggered by an infectious, neoplastic, or autoimmune event. The involvement of cytomegalovirus (CMV) in the onset of HLH is subject to debate, and the epidemiology of CMV-associated HLH (HLH-CMV) remains poorly characterized. We identified 5 cases of HLH-CMV in our hospital, systematically searched the PubMed database for publications on HLH-CMV, and reviewed 57 publications with a total of 67 cases of HLH-CMV. Only 48 patients (71.6%) were immunodeficient, suggesting that HLH-CMV can occur in immunocompetent patients. The major cause of underlying immunodepression (51%) was inflammatory bowel disease (mainly treated with azathioprine). CMV infection was nearly always symptomatic, and lung involvement was frequent (31 cases). Fifty-five patients recovered. Nineteen patients were treated for CMV infection only and had a good outcome, suggesting that antiviral drugs might be the cornerstone of HLH-CMV treatment.
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Affiliation(s)
- Kevin Chevalier
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Julien Schmidt
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Paul Coppo
- Sorbonne Université, AP-HP, Hôpital St. Antoine, service d'hématologie clinique et thérapie cellulaire, Paris, France
| | - Lionel Galicier
- Université Paris Cité, AP-HP, Hôpital Saint-Louis, service d'immunologie clinique, Paris, France
| | - Nicolas Noël
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Olivier Lambotte
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
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8
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Khalatbari H, Shulkin BL, Parisi MT. Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity. Semin Nucl Med 2023; 53:18-36. [PMID: 36307254 DOI: 10.1053/j.semnuclmed.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
The most common indication for 18F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on 18F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the 18F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Barry L Shulkin
- Department of Diagnostic Radiology, St. Jude Children's Research Hospital, Memphis, TN.
| | - Marguerite T Parisi
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
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Efficacy of Tocilizumab in Management of COVID-19 Patients Admitted to Intensive Care Units: A Multicenter Retrospective Cohort Study. Medicina (B Aires) 2022; 59:medicina59010053. [PMID: 36676678 PMCID: PMC9864835 DOI: 10.3390/medicina59010053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
Background and Objectives: Mortality and illness due to COVID-19 have been linked to a condition known as cytokine release syndrome (CRS) that is characterized by excessive production of inflammatory cytokines, particularly interleukin-6 (IL-6). Tocilizumab (TCZ), a recent IL-6 antagonist, has been redeployed as adjunctive treatment for CRS remission in COVID-19 patients. This study aimed to determine the efficacy of Tocilizumab on patients' survival and the length of stay in hospitalized COVID-19 patients admitted to the intensive care unit. Methods: Between January 2021 and June 2021, a multicenter retrospective cohort study was carried out in six tertiary care hospitals in Egypt's governorate of Giza. Based on the use of TCZ during ICU stay, eligible patients were divided into two groups (control vs. TCZ). In-hospital mortality was the main outcome. Results: A total of 740 patient data records were included in the analysis, where 630 patients followed the routine COVID-19 protocol, while 110 patients received TCZ, need to different respiratory support after hospitalization, and inflammatory mediators such as C-reactive protein (CRP), ferritin, and Lactate dehydrogenase (LDH) showed a statistically significant difference between the TCZ group and the control group. Regarding the primary outcome (discharged alive or death) and neither the secondary outcome (length of hospital stay), there is no statistically significant difference between patients treated with TCZ and the control group. Conclusions: Our cohort of patients with moderate to severe COVID-19 did not assert a reduction in the risk of mortality or the length of stay (LOS) after TCZ administration.
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Dupont T, Darmon M, Mariotte E, Lemiale V, Fadlallah J, Mirouse A, Zafrani L, Azoulay E, Valade S. Etoposide treatment in secondary hemophagocytic syndrome: impact on healthcare-associated infections and survival. Ann Intensive Care 2022; 12:101. [PMID: 36307626 PMCID: PMC9616615 DOI: 10.1186/s13613-022-01075-9] [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: 07/06/2022] [Accepted: 10/15/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Etoposide remains the cornerstone of symptomatic management of critically ill patients with secondary hemophagocytic syndrome (sHS). Risk of healthcare-associated infections (HAIs) in this setting with etoposide has never been assessed. We sought to evaluate the association between etoposide administration, HAIs occurrence and survival in critically ill adult patients with sHS. In this retrospective single-center study conducted in a university hospital ICU between January 2007 and March 2020, all consecutive patients with sHS were included. HAIs were defined as any microbiologically documented infection throughout ICU stay. Competing risk survival analysis was performed to determine factors associated with HAIs. Propensity score-based overlap weighting was performed to adjust for factors associated with etoposide use. RESULTS 168 patients with a median age of 49 [38, 59] were included. Forty-three (25.6%) patients presented with at least 1 microbiologically documented HAI throughout ICU stay. After adjustment, cumulative incidence of HAI was higher in patients receiving etoposide (p = 0.007), while survival was unaffected by etoposide status (p = 0.824). By multivariable analysis, etoposide treatment was associated with a higher incidence of HAIs (sHR 3.75 [1.05, 6.67]), whereas no association with survival (sHR 0.53 [0.20, 1.98]) was found. Other factors associated with increased mortality after adjustment included age, immunodepression, male sex, SOFA score > 13, and occurrence of HAI. CONCLUSIONS In patients with sHS, etoposide treatment is independently associated with increased occurrence of HAIs, whereas no association with survival was found. Intensivists should be aware of increased infectious risk, to promptly detect and treat infections in this specific setting. Studies to assess benefits from prophylactic anti-infectious agents in this setting are warranted and the lack of benefit of etoposide on survival needs to be interpreted cautiously.
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Affiliation(s)
- Thibault Dupont
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France.
- Université de Paris, Paris, France.
| | - Michael Darmon
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
- UMR 1153, Center of Epidemiology and Biostatistics, ECSTRA Team and Clinical Epidemiology, Sorbonne Paris Cité, CRESS, INSERM, Paris, France
| | - Eric Mariotte
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
| | - Virginie Lemiale
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
| | - Jehane Fadlallah
- Université de Paris, Paris, France
- UMR 1153, Center of Epidemiology and Biostatistics, ECSTRA Team and Clinical Epidemiology, Sorbonne Paris Cité, CRESS, INSERM, Paris, France
- Assistance Publique-Hôpitaux de Paris (APHP), Immunology Department, Saint-Louis University Hospital, Paris, France
| | - Adrien Mirouse
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
| | - Lara Zafrani
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
| | - Elie Azoulay
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
| | - Sandrine Valade
- Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université de Paris, Paris, France
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11
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Kolachana S, Malik A, Nanjudappa A, Iding J, Bhansali D, Haas CJ. Haemophagocytic lymphocytic histiocytosis/macrophage activation syndrome with acute inflammatory gastroenteritis. BMJ Case Rep 2022; 15:e250809. [PMID: 36002177 PMCID: PMC9413288 DOI: 10.1136/bcr-2022-250809] [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] [Accepted: 07/31/2022] [Indexed: 11/03/2022] Open
Abstract
Haemophagocytic lymphocytic histiocytosis (HLH) is a rare, life-threatening condition caused by abnormal activation of cytotoxic T lymphocytes, natural killer cells and macrophages resulting in hypercytokinaemia and immune-mediated injury of multiple organ systems. Secondary HLH occurs in the setting of a malignant, infectious or autoimmune stimulus. Macrophage activation syndrome (MAS) is the term used to describe HLH that develops secondary to rheumatological diseases such as lupus and juvenile idiopathic arthritis, among others. Commonly observed and documented symptoms include fever, organomegaly and lymphadenopathy. Given the potential for multiorgan failure in HLH/MAS, early identification, diagnosis and initiation of treatment is essential. We present a case of secondary HLH/MAS with acute inflammatory gastroenteritis in a middle-aged woman with a history of systemic lupus erythematosus.
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Affiliation(s)
- Sindhura Kolachana
- Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Albahi Malik
- Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | | | - Jeffrey Iding
- Pathology, MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
| | - Deepty Bhansali
- Pathology, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Christopher J Haas
- Medicine, MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
- Medicine, MedStar Harbor Hospital, Baltimore, Maryland, USA
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Acharya S, Shukla S, Sontakke T, VS I, Bagga C, Dronamraju S, Giri A. A Case Report of Hemophagocytic Lymphohistiocytosis (HLH) - An Unusual Complication of Dengue Infection. Cureus 2022; 14:e26504. [PMID: 35923479 PMCID: PMC9339372 DOI: 10.7759/cureus.26504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an autoimmune phenomenon characterized by reactive hyperactivity of cytotoxic T cells and histiocytes, leading to hypercytokinemic injury to cells and organ system, which leads to multiorgan dysfunction and ultimate failure. Epstein-Barr virus (EBV) is most commonly associated with secondary HLH with high mortality, but increasing evidence suggests the association of the dengue virus. When associated with dengue infection, it carries a grave prognosis and correlates with the disease severity. Furthermore, it overlaps with dengue sepsis, so it can often be misdiagnosed as sepsis. Typically the patients have hyperferritinemia, hypertriglyceridemia, transaminitis, and marrow features suggestive of hemophagocytosis. The treatment is usually systemic corticosteroids, intravenous immunoglobulin, and chemotherapy with etoposide. We present a case of a 25-year-old male patient who had a dengue infection and further developed HLH with pulmonary infiltrates. Clinical suspicion alerted us to look for other evidence of HLH on the fourth day of admission, and appropriate investigations were done. Diagnosis of HLH was confirmed by HLH-2004, HScore criteria, and bone marrow aspirate examination. Treatment was given in the form of corticosteroids and chemotherapy along with other supportive measures. The patient responded to the line of management.
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Zhou JC, Tan BB, Huang Y, Wu YY, Bai ZJ, Liang ML, Zhao WH. Intrathoracic infections in Hodgkin lymphoma (HL) patients may cooperate with HL to trigger hemophagocytic lymphohistiocytosis: A retrospective study. Medicine (Baltimore) 2022; 101:e29756. [PMID: 35777035 PMCID: PMC9239602 DOI: 10.1097/md.0000000000029756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Hodgkin lymphoma (HL)-related hemophagocytic lymphohistiocytosis (HLH) has been reported in the literature; however, there is almost no literature on the factors related to HL triggering HLH. One hundred forty patients with HL were retrospectively analyzed. The incidence of HL-related HLH (we call HL-related HLH as HL-HLH). And all HL-HLH patients in our cohort had HLH as the first manifestation and its clinical characteristics and the role of intrathoracic infection (ITI) in triggering HLH are discussed. The 140 patients with HL mainly included mixed-cellularity classic HL (MCCHL) in 81 (57.9%), nodular sclerosis classic HL (NSCHL) in 36 (25.7%), and lymphacyte-rich classic HL in 14 (10.0%) patients. Of the 137 patients who underwent chest computed tomography scans on admission, 44 had ITI, and most of these ITI were mildly ill and had no respiratory symptoms. Among 140 HL patients, 8 patients from MCCHL were diagnosed as HL-HLH. Among 81 MCCHL patients, 26 patients with ITI had a significantly higher incidence of HL-HLH than those without ITI (26.9% vs 1.8%, P = .002). The median survival time of 8 cases of HL-HLH was only 2 months. When HL patients were first admitted to the hospital, 5.7% had HLH as the first manifestation, and 32.1% had ITI. These ITI can cooperate with HL to trigger HLH, despite their mild illness. The prognosis of HL-HLH was poor.
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Affiliation(s)
- Ji-Cheng Zhou
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
- *Correspondence: Ji-Cheng Zhou, Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, No. 6, Shuangyong Road, Nanning, 530021 Guangxi, P. R. China (e-mail: )
| | - Bin-Bin Tan
- Department of Hematology, Baise People’s Hospital, Baise, Guangxi, China
- *Correspondence: Ji-Cheng Zhou, Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, No. 6, Shuangyong Road, Nanning, 530021 Guangxi, P. R. China (e-mail: )
| | - Yan Huang
- Department of Hematology, Baise People’s Hospital, Baise, Guangxi, China
| | - Yin-Ying Wu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Zhen-Jie Bai
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Min-Lan Liang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Wei-Hua Zhao
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
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Characteristics and prognostic value of pleural effusion in secondary hemophagocytic lymphohistiocytosis. Int J Hematol 2022; 116:102-109. [PMID: 35338447 PMCID: PMC8956144 DOI: 10.1007/s12185-022-03333-9] [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: 10/25/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022]
Abstract
The clinical features of patients with secondary hemophagocytic lymphohistiocytosis (sHLH) complicated with pleural effusion have rarely been evaluated. We retrospectively analyzed 203 patients newly diagnosed with sHLH from July 2015 to July 2019 according to the HLH-2004 protocol. Baseline characteristics, laboratory results, and imaging were reviewed. Pleural effusion was found in 58.6% of the studied sHLH population, and characteristic imaging findings were minimal volume and bilaterality. Patients with pleural effusion had lower PLT counts, HB levels and ALB levels as well as higher sCD25 levels than those without pleural effusion (all p values < 0.05). Multivariate analyses showed that lg(sCD25) and PLT ≤ 65 × 109/L were significant risk factors for developing pleural effusion in sHLH. Regarding prognostic value, survival analysis showed a lower survival probability for patients with pleural effusion than for those without pleural effusion (median OS, 90 vs. 164 days, p = 0.028). In multivariate analysis, pleural effusion was an independent prognostic factor for overall survival (OS) (HR 2.68; 95% CI 1.18–6.11, p = 0.019). Pleural effusion is frequently found in patients with sHLH and is associated with greater inflammation and worse outcomes.
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15
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Shah NN, Dar KA, Quibtiya S, Din Azad AMU, Mushtaq M, Bashir SM, Rather MA, Ali SI, Sheikh WM, Nabi SU. Repurposing of Mycobacterium indicus pranii for the severe form of COVID -19 patients in India: A cohort study. J Med Virol 2021; 94:1906-1919. [PMID: 34951021 PMCID: PMC9015534 DOI: 10.1002/jmv.27547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022]
Abstract
SARS-CoV-2 induces the production of proinflammatory cytokines, which results in cytokine storm, and immune-modulators like Mycobacterium indicus pranii (MIP) might ameliorate COVID -19 related cytokine storm. Therefore, the present study evaluates whether MIP offers an advantage in the treatment of severe COVID -19 patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Prospective MIP cohort Study was conducted in chest disease hospitals in Srinagar, Jammu and Kashmir, India. In the present prospective, randomized clinical study, critically severe COVID -19 patients were divided into two groups, the MIP group (n=105) and Best Standard Treatment group (n=210). Procalcitonin, Ferritin, Hs-CRP (High Sensitive C Reactive Protein), D-dimer levels and Interleukin levels on 5th -day post-treatment were significantly reduced in the MIP group compared to the BST group. Compared to the BST group, 105 consecutive patients with severe COVID -19 in the MIP group reported early weaning off mechanical ventilation, resolution of chest architecture (CT scan), significant increase in SpO2 levels and decreased mortality with hazard ratio-0.234 (95% CI-0.264-2.31) (p-value-0.001). MIP restored SpO2 , immune/inflammatory response, normalized lung abnormalities (Chest CT scan), and reduced mortality without any serious complications. However, there is a need for placebo-controlled double-blind and controlled clinical trials to confirm the efficacy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Naveed Nazir Shah
- Department of Chest Medicine, Govt. Medical College, Srinagar, Jammu & Kashmir, India
| | - Khurshid Ahmad Dar
- Department of Chest Medicine, Govt. Medical College, Srinagar, Jammu & Kashmir, India
| | - Syed Quibtiya
- Department of General Surgery, Sher-I-Kashmir Institute of Medical Sciences, Medical College, Srinagar, Jammu & Kashmir, India
| | | | - Mehvish Mushtaq
- Department of Chest Medicine, Govt. Medical College, Srinagar, Jammu & Kashmir, India
| | - Showkeen Muzamil Bashir
- Biochemistry & Molecular biology Lab, Division of veterinary Biochemistry, Faculty of Veterinary Sciences (F.V.Sc.) and Animal Husbandry (A.H), SKUAST-K, Shuhama, Alusteng, Srinagar, Jammu & Kashmir, India
| | - Muzafar Ahmad Rather
- Biochemistry & Molecular biology Lab, Division of veterinary Biochemistry, Faculty of Veterinary Sciences (F.V.Sc.) and Animal Husbandry (A.H), SKUAST-K, Shuhama, Alusteng, Srinagar, Jammu & Kashmir, India
| | - Sofi Imtiyaz Ali
- Biochemistry & Molecular biology Lab, Division of veterinary Biochemistry, Faculty of Veterinary Sciences (F.V.Sc.) and Animal Husbandry (A.H), SKUAST-K, Shuhama, Alusteng, Srinagar, Jammu & Kashmir, India
| | - Wajid Mohammad Sheikh
- Biochemistry & Molecular biology Lab, Division of veterinary Biochemistry, Faculty of Veterinary Sciences (F.V.Sc.) and Animal Husbandry (A.H), SKUAST-K, Shuhama, Alusteng, Srinagar, Jammu & Kashmir, India
| | - Showkat Ul Nabi
- Large Animal Diagnostic Laboratory, Department of Clinical Veterinary Medicine, Ethics & Jurisprudence, F.V.Sc. & A.H, SKUAST-K, Shuhama, Alusteng, Srinagar, Jammu & Kashmir, India
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16
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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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17
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Pasero D, Terragni P. Should we treat fever in critically ill COVID-19 patients? Minerva Anestesiol 2021; 87:1168-1170. [PMID: 34781673 DOI: 10.23736/s0375-9393.21.16199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Daniela Pasero
- Department of Medical, Surgical and Experimental Science, University of Sassari, Sassari, Italy - .,Dipartimento di Emergenze Urgenze, AOU Sassari, Sassari, Italy -
| | - Pierpaolo Terragni
- Department of Medical, Surgical and Experimental Science, University of Sassari, Sassari, Italy.,Dipartimento di Emergenze Urgenze, AOU Sassari, Sassari, Italy
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18
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Fabrazzo M, Russo A, Camerlengo A, Tucci C, Luciano M, De Santis V, Perris F, Catapano F, Coppola N. Delirium and Cognitive Impairment as Predisposing Factors of COVID-19 Infection in Neuropsychiatric Patients: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1244. [PMID: 34833462 PMCID: PMC8622938 DOI: 10.3390/medicina57111244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
SARS-CoV-2 neuroinvasive and neurotropic abilities may underlie delirium onset and neuropsychiatric outcomes. Only a limited number of studies have addressed the potential effect of SARS-CoV-2 infection on mental health so far. Most studies mainly reported the acute onset of mixed neuropsychiatric conditions in patients infected with SARS-CoV-2, characterized by agitated behavior, altered level of consciousness, and disorganized thinking, regardless of psychological or socioeconomic triggering factors. The present narrative review aims to analyze and discuss the mechanisms underlying the neuroinvasive/neurotropic properties of SARS-CoV-2 and the subsequent mental complications. Delirium appeared as a clinical manifestation of SARS-CoV-2 brain infection in some patients, without systemic or multiple organ failure symptoms. A small number of studies demonstrated that neuropsychiatric symptoms associated with COVID-19, initially presenting as a confused state, may subsequently evolve in a way that is consistent with the patients' neuropsychiatric history. A literature analysis on this topic prevalently showed case reports and case series of patients presenting delirium or delirium-like symptoms as the main outburst of COVID-19, plus a cognitive impairment, from mild to severe, which pre-existed or was demonstrated during the acute phase or after infection. Dementia appeared as one of the most frequent predisposing factors to SARS-CoV-2 infection complicated with delirium. Instead, contrasting data emerged on the potential link between COVID-19 and delirium in patients with cognitive impairment and without a neuropsychiatric history. Therefore, clinicians should contemplate the possibility that COVID-19 appears as delirium followed by a psychiatric exacerbation, even without other systemic symptoms. In addition, cognitive impairment might act as a predisposing factor for COVID-19 in patients with delirium.
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Affiliation(s)
- Michele Fabrazzo
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Antonio Russo
- Infectious Diseases Unit, Department of Mental Health and Public Medicine, University of Campania “Luigi Vanvitelli”, Via S. Pansini 5, 80131 Naples, Italy; (A.R.); (N.C.)
| | - Alessio Camerlengo
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Claudia Tucci
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Mario Luciano
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Valeria De Santis
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Francesco Perris
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Francesco Catapano
- Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Largo Madonna delle Grazie 1, 80138 Naples, Italy; (A.C.); (C.T.); (M.L.); (V.D.S.); (F.P.); (F.C.)
| | - Nicola Coppola
- Infectious Diseases Unit, Department of Mental Health and Public Medicine, University of Campania “Luigi Vanvitelli”, Via S. Pansini 5, 80131 Naples, Italy; (A.R.); (N.C.)
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19
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Sheik Abdul N, Marnewick JL. Rooibos, a supportive role to play during the COVID-19 pandemic? J Funct Foods 2021; 86:104684. [PMID: 34422116 PMCID: PMC8367744 DOI: 10.1016/j.jff.2021.104684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/21/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023] Open
Abstract
This article presents the potential health benefits of Rooibos to be considered a support during the COVID-19 pandemic. The recent pandemic of COVID-19 has led to severe morbidity and mortality. The highly infectious SARS-CoV-2 is known to prime a cytokine storm in patients and progression to acute lung injury/acute respiratory distress syndrome. Based on clinical features, the pathology of acute respiratory disorder induced by SARS-CoV-2 suggests that excessive inflammation, oxidative stress, and dysregulation of the renin angiotensin system are likely contributors to the COVID-19 disease. Rooibos, a well-known herbal tea, consumed for centuries, has displayed potent anti-inflammatory, antioxidant, redox modulating, anti-diabetic, anti-cancer, cardiometabolic support and organoprotective potential. This article describes how Rooibos can potentially play a supportive role by modulating the risk of some of the comorbidities associated with COVID-19 in order to promote general health during infections.
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Affiliation(s)
- Naeem Sheik Abdul
- Applied Microbial and Health Biotechnology Institute, Cape Peninsula University of Technology, South Africa
| | - Jeanine L Marnewick
- Applied Microbial and Health Biotechnology Institute, Cape Peninsula University of Technology, South Africa
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20
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Ruscitti P, Di Cola I, Berardicurti O, Conforti A, Iacono D, Pantano I, Rozza G, Rossi S, De Ludovico S, Balduzzi S, Vitale A, Caso F, Costa L, Prete M, Navarini L, Atzeni F, Guggino G, Perosa F, Cantarini L, Frediani B, Montecucco C, Ciccia F, Giacomelli R, Cipriani P. Impact of smoking habit on adult-onset Still's disease prognosis, findings from a multicentre observational study. Clin Rheumatol 2021; 41:641-647. [PMID: 34636022 DOI: 10.1007/s10067-021-05929-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 12/22/2022]
Abstract
The objective of this study is to describe the possible prognostic impact of smoking habit on adult-onset Still's disease (AOSD) patients, by the assessment of clinical characteristics, life-threatening complications occurrence, and mortality in smokers than non-smokers. A multicentre retrospective study of prospectively followed-up AOSD patients included in Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort was conducted. Out of 185 AOSD assessed patients, 45 smokers were identified. These showed a higher frequency of pericarditis (35.5% vs 16.4%, p = 0.011), pleuritis (33.3% vs 14.3%, p = 0.008), and abdominal pain (17.7% vs 6.4%, p = 0.035). Furthermore, smokers showed higher values of systemic score (6.4 ± 2.2 vs 5.4 ± 1.8, p = 0.004), an increased rate of macrophage activation syndrome (MAS) (28.9% vs 6.4%, p < 0.0001) and of parenchymal lung disease (17.7% vs 12.6%, p = 0.035). Although not significant, these patients more frequently experienced a poor prognosis (13.3% vs 4.3%, p = 0.074). Smoking habit predicted MAS occurrence in both univariate (HR: 5.98, 95% CI: 2.45-14.57, p < 0.0001) and multivariate regression models (HR: 6.21, 95% CI: 2.46-15.70, p < 0.0001). Smokers had a significant higher risk of parenchymal lung disease in both univariate (HR: 3.97, 95% CI: 1.43-11.02, p = 0.008) and multivariate regression models (HR: 3.90, 95% CI: 1.36-11.23, p = 0.012). Smoking habit also increased the risk of mortality in univariate regression model (HR: 4.25, 95% CI: 1.33-13.55, p = 0.015). Smoking habit resulted to be a negative prognostic factor on AOSD patients. Smokers were characterised by a higher frequency of serositis and higher values of systemic score. Additionally, these patients were more frequently burdened by MAS and parenchymal lung disease associated with a poor prognosis. Key points • Smoking habit resulted to be a negative prognostic factor on AOSD. • Smokers were characterised by an increased frequency of serositis and higher values of systemic score. • Cigarette exposure was associated with MAS and parenchymal lung disease in AOSD.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, delta 6 building, PO box 67100, L'Aquila, Italy.
| | - Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, delta 6 building, PO box 67100, L'Aquila, Italy
| | - Onorina Berardicurti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, delta 6 building, PO box 67100, L'Aquila, Italy
| | - Alessandro Conforti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, delta 6 building, PO box 67100, L'Aquila, Italy
| | - Daniela Iacono
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ilenia Pantano
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gelsomina Rozza
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Silvia Rossi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stefano De Ludovico
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Silvia Balduzzi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Antonio Vitale
- Research Center of Systemic Auto Inflammatory Diseases, Behçet's Disease and Rheumatology-Ophthalmology Collaborative Uveitis Center, Rheumatology Unit, Policlinico "Le Scotte", Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Francesco Caso
- Deparment of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luisa Costa
- Deparment of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Marcella Prete
- Rheumatic and Systemic Autoimmune Diseases Unit, Department of Biomedical Science and Human Oncology (DIMO), University of Bari Medical School, Bari, Italy
| | - Luca Navarini
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuliana Guggino
- Rheumatology Section, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University Hospital "P. Giaccone", Palermo, Italy
| | - Federico Perosa
- Rheumatic and Systemic Autoimmune Diseases Unit, Department of Biomedical Science and Human Oncology (DIMO), University of Bari Medical School, Bari, Italy
| | - Luca Cantarini
- Research Center of Systemic Auto Inflammatory Diseases, Behçet's Disease and Rheumatology-Ophthalmology Collaborative Uveitis Center, Rheumatology Unit, Policlinico "Le Scotte", Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Auto Inflammatory Diseases, Behçet's Disease and Rheumatology-Ophthalmology Collaborative Uveitis Center, Rheumatology Unit, Policlinico "Le Scotte", Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Francesco Ciccia
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberto Giacomelli
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, delta 6 building, PO box 67100, L'Aquila, Italy
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Neycheva S, Oparanov B, Kamburova A, Karalilova R, Stoeva V. Hemophagocytic Lymphohistiocytosis Triggered by Leishmaniasis: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933012. [PMID: 34613957 PMCID: PMC8503795 DOI: 10.12659/ajcr.933012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Patient: Female, 40-year-old
Final Diagnosis: Hemophagocytic Lymphohistiocytosis
Symptoms: Chills • fatigue • fever • myalgia • sweating
Medication: —
Clinical Procedure: —
Specialty: Infectious Diseases
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Affiliation(s)
- Stefka Neycheva
- Department of Rheumatology, Military Medical Academy, Sofia, Bulgaria
| | - Boycho Oparanov
- Department of Rheumatology, Military Medical Academy, Sofia, Bulgaria
| | - Adriana Kamburova
- Department of Rheumatology, Military Medical Academy, Sofia, Bulgaria
| | - Rositsa Karalilova
- Clinic of Rheumatology, Medical University of Plovdiv, University Hospital "Kaspela", Plovdiv, Bulgaria
| | - Vera Stoeva
- Department of Hematology, Specialized Hospital for Active Treatment of Hematologic Diseases, Sofia, Bulgaria
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22
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Consensus-Based Guidelines for the Recognition, Diagnosis, and Management of Hemophagocytic Lymphohistiocytosis in Critically Ill Children and Adults. Crit Care Med 2021; 50:860-872. [PMID: 34605776 DOI: 10.1097/ccm.0000000000005361] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome that often requires critical care support and remains difficult to diagnose. These guidelines are meant to aid in the early recognition, diagnosis, supportive care, and treatment of patients with hemophagocytic lymphohistiocytosis in ICUs. DATA SOURCES The literature searches were performed with PubMed (MEDLINE). STUDY SELECTION Keywords and medical subject headings terms for literature search included "macrophage activation syndrome," hemophagocytic lymphohistiocytosis," and "hemophagocytic syndrome." DATA EXTRACTION The Histiocyte Society developed these consensus recommendations on the basis of published reports and expert opinions with level of evidence provided for each recommendation. They were endorsed by the Society of Critical Care Medicine. DATA SYNTHESIS Testing for hemophagocytic lymphohistiocytosis should be initiated promptly in all patients admitted to ICUs with an unexplained or disproportionate inflammatory response, especially those with rapid clinical deterioration. Meeting five or more of eight hemophagocytic lymphohistiocytosis 2004 diagnostic criteria serves as a valuable diagnostic tool for hemophagocytic lymphohistiocytosis. Early aggressive critical care interventions are often required to manage the multisystem organ failure associated with hemophagocytic lymphohistiocytosis. Thorough investigation of the underlying triggers of hemophagocytic lymphohistiocytosis, including infections, malignancies, and autoimmune/autoinflammatory diseases, is essential. Early steroid treatment is indicated for patients with familial hemophagocytic lymphohistiocytosis and is often valuable in patients with acquired hemophagocytic lymphohistiocytosis (i.e., secondary hemophagocytic lymphohistiocytosis) without previous therapy, including macrophage activation syndrome (hemophagocytic lymphohistiocytosis secondary to autoimmune/autoinflammatory disease) without persistent or relapsing disease. Steroid treatment should not be delayed, particularly if organ dysfunction is present. In patients with macrophage activation syndrome, whose disease does not sufficiently respond, interleukin-1 inhibition and/or cyclosporine A is recommended. In familial hemophagocytic lymphohistiocytosis and severe, persistent, or relapsing secondary macrophage activation syndrome, the addition of prompt individualized, age-adjusted etoposide treatment is recommended. CONCLUSIONS Further studies are needed to determine optimal treatment for patients with hemophagocytic lymphohistiocytosis in ICUs, including the use of novel and adjunct therapies.
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Wilson-Morkeh H, Frise C, Youngstein T. Haemophagocytic lymphohistiocytosis in pregnancy. Obstet Med 2021; 15:79-90. [DOI: 10.1177/1753495x211011913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.
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Affiliation(s)
- Harold Wilson-Morkeh
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Charlotte Frise
- Fetal-Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- De Swiet’s Obstetric Medicine Centre, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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24
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Koda E, Nishine H, Saiki Y, Tsunoda A, Usuba A, Furuya N, Mineshita M. Untreated Squamous Cell Lung Carcinoma May Contribute to the Occurrence of Hemophagocytic Syndrome. Intern Med 2021; 60:2997-3002. [PMID: 33775994 PMCID: PMC8502648 DOI: 10.2169/internalmedicine.5892-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/08/2021] [Indexed: 11/15/2022] Open
Abstract
A 44-year-old man presented at our hospital to be evaluated for persistent fever and dyspnea. A chest computed tomography (CT) scan showed diffuse ground glass shadows and a left hilar tumor shadow. Upon further examination, he was found to have leukopenia, thrombocytopenia, and elevated lactate dehydrogenase and ferritin levels. He was diagnosed with both squamous cell lung carcinoma by a transbronchial lung biopsy and hemophagocytic syndrome by a bone marrow biopsy. After receiving treatment with dexamethasone and etoposide, the blood test abnormalities and performance status improved. Chemotherapy for lung cancer was initiated. He had a partial response after first-line chemotherapy and thereafter underwent left upper sleeve lobectomy.
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Affiliation(s)
- Eriko Koda
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Hiroki Nishine
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yusuke Saiki
- Division of Hematology and Oncology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Akihito Tsunoda
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Ayano Usuba
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Naoki Furuya
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Masamichi Mineshita
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
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25
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Bukhari MH, Zain S, Syed M. The new criteria for a COVID19 patient for the clinical practice to determine the need for an early therapeutic regimen and to decrease mortality. Pak J Med Sci 2021; 37:1536-1539. [PMID: 34475944 PMCID: PMC8377921 DOI: 10.12669/pjms.37.5.3630] [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: 12/03/2020] [Revised: 01/01/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
A new predictive criterion is being proposed for the determination of cytokine storm (CS) in COVID-19 (COVID-CS). It is comprised of results of laboratory that associate the pro-inflammatory status, systemic cell death, multi-organ tissue damage, and pre-renal electrolyte imbalance. The data identifies the patients' stay in hospitals and their mortality with the relevance of hyper-inflammation and tissue damage during the CS. The criteria can be readily used in clinical practice to determine the need for an early therapeutic regimen, block the hyper-immune response and possibly decrease mortality. It helps to understand the nature of the virus by following a specific criterion to predict the disease. The SARS-CoV-2 tells us in few days what nature has decided for the patient i.e., recovery, death or permanent disability.
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Affiliation(s)
- Mulazim Hussain Bukhari
- Mulazim Hussain Bukhari, Principal Azad Jammu Kashmir Medical College, Muzaffarabad, Azad Jammu and Kashmir, Pakistan
| | - Shahzadi Zain
- Shahzadi Zain, Schulich School of Medicine and Dentistry, Western University, Canada
| | - Mobeen Syed
- Mobeen Syed, DRBEEN.COM Personalized Medical Education, California, USA
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26
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Vannucchi AM, Mortara A, D’Alessio A, Morelli M, Tedeschi A, Festuccia MB, Monforte AD, Capochiani E, Selleri C, Simonetti F, Saracino A, Rapezzi D, Badagliacca MR, Falasca K, Molteni A, Palazzolo R, Schettino G, Bocchia M, Turrini M, Ascierto PA, Zuurman M, Paley C, Coco P, Saglio G. JAK Inhibition with Ruxolitinib in Patients with COVID-19 and Severe Pneumonia: Multicenter Clinical Experience from a Compassionate Use Program in Italy. J Clin Med 2021; 10:jcm10163752. [PMID: 34442045 PMCID: PMC8397012 DOI: 10.3390/jcm10163752] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 12/15/2022] Open
Abstract
Jak inhibitors are potent anti-inflammatory drugs that have the potential to dampen the hyperactive inflammatory response associated with severe COVID-19. We reviewed the clinical outcomes of 218 patients with COVID-19 hospitalized for severe pneumonia and treated with ruxolitinib through a compassionate use program. Data on the duration of treatment; outcomes at 4, 7, 14, and 28 days; oxygen support requirements; clinical status; and laboratory parameters were retrospectively collected. Overall, according to the physician evaluation, 66.5% of patients showed improvement at follow-up; of these, 83.5% showed improvement by day 7. Oxygen support status also showed improvement, and by day 7, 21.6% of patients were on ambient air, compared with 1.4% at baseline, which increased to 48.2% by day 28. Significant decreases in C-reactive protein and increases in the lymphocyte total count were already observed by day 4, which seemed to correlate with a positive outcome. At the end of the observation period, 87.2% of patients were alive. No unexpected safety findings were observed, and grade 3/4 adverse events were reported in 6.9% of patients.
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Affiliation(s)
- Alessandro Maria Vannucchi
- Center Research Innovation of Myeloproliferative Neoplasms (CRIMM), SOD Hematology, University of Florence and AOU Careggi, 50134 Florence, Italy;
| | - Andrea Mortara
- Department of Clinical Cardiology, Policlinico di Monza, 28100 Monza, Italy;
| | - Andrea D’Alessio
- COVID Medical Department, Policlinico S. Marco, Gruppo San Donato University and Research Hospital, 24040 Zingonia, Italy;
| | - Mara Morelli
- Novartis Farma SpA, 21040 Origgio, Italy; (M.M.); (M.Z.); (P.C.)
| | - Alberto Tedeschi
- U.O.C. Medicina Generale, Ospedale Bolognini, ASST Bergamo Est, 24068 Seriate, Italy;
| | | | | | - Enrico Capochiani
- UOC Ematologia, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | - Carmine Selleri
- Hematology, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy;
| | | | - Annalisa Saracino
- Clinica Malattie Infettive, Dip. Scienze Biomediche ed Oncologia Umana, Università degli Studi di Bari, 70124 Bari, Italy;
| | - Davide Rapezzi
- S.C. Ematologia Ospedale S. Croce e Carle, 12100 Cuneo, Italy;
| | - Maria Rita Badagliacca
- UOS UFA UOC Farmacia Ospedaliera Distretto Ospedaliero CL1-P.O.S. Elia, Azienda Sanitaria Provinciale di Caltanissetta, 93100 Caltanissetta, Italy;
| | - Katia Falasca
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University G. d’Annunzio, Chieti-Pescara, 66100 Chieti, Italy;
| | | | | | | | - Monica Bocchia
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, 53100 Siena, Italy;
| | - Mauro Turrini
- Division of Hematology, Department of Medicine, Valduce Hospital, 22100 Como, Italy;
| | - Paolo A. Ascierto
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale per lo Studio e la Cura dei Tumori IRCCS Fondazione G. Pascale, 80131 Naples, Italy;
| | - Mike Zuurman
- Novartis Farma SpA, 21040 Origgio, Italy; (M.M.); (M.Z.); (P.C.)
- Novartis Pharma BV, 1101 Amsterdam, The Netherlands
| | | | - Paola Coco
- Novartis Farma SpA, 21040 Origgio, Italy; (M.M.); (M.Z.); (P.C.)
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences of the University of Turin, San Luigi University Hospital, 10143 Orbassano, Italy
- Correspondence:
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Abstract
ABSTRACT The ongoing coronavirus disease 2019 (COVID-19) pandemic has swept over the world and causes thousands of deaths. Although the clinical features of COVID-19 become much clearer than before, there are still further problems with the pathophysiological process and treatments of severe patients. One primary problem is with the paradoxical immune states in severe patients with COVID-19. Studies indicate that Severe Acute Respiratory Syndrome Coronavirus 2 can attack the immune system, manifested as a state of immunosuppression with a decrease in lymphocytes, whereas a state of hyperinflammation, presenting as elevated cytokine levels, is also detected in COVID-19. Therefore, discussing the specific status of immunity in COVID-19 will contribute to the understanding of its pathophysiology and the search for appropriate treatments. Here, we review all the available literature concerning the different immune states in COVID-19 and the underlying pathophysiological mechanisms. In addition, the association between immune states and the development and severity of disease as well as the impact on the selection of immunotherapy strategies are discussed in our review.
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Affiliation(s)
- Ye Liu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Hubei, China
| | - Yiming Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Hubei, China
| | - Dongxue Xu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Hubei, China
| | - Jing Zhang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Hubei, China
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Hubei, China
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28
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An Atypical Presentation of Hemophagocytic Lymphohistiocytosis (HLH) Secondary to Occult Hodgkin Lymphoma. Case Rep Hematol 2021; 2021:6672257. [PMID: 34341690 PMCID: PMC8325589 DOI: 10.1155/2021/6672257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome of immune system dysregulation characterized by the phagocytosis of various cells by histiocytes in the bone marrow. HLH can present in one of the two ways: primary HLH, which is caused by mutations in genes essential to T and NK-cell function, and secondary HLH, typically caused by Epstein-Barr virus (EBV) infection or malignancy. Because of the rapid progression and high mortality of this disease, prompt diagnosis is essential to good outcomes. Here, we report the 2-month clinical course of a patient who presented with altered mental status and recurrent fever of unknown origin. Initially, he did not meet diagnostic criteria for HLH and had a negative bone marrow biopsy; however, he eventually progressed to full-blown HLH secondary to occult Hodgkin lymphoma. This case is unusual for the slow and smoldering course of the patient's disease and highlights the importance of aggressively searching for potential malignancies to ensure the initiation of definitive therapy as soon as possible.
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29
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Muras-Szwedziak K, Tylski M, Masajtis-Zagajewska A, Nowicki M. Secondary Hemophagocytic Lymphohistiocytosis Complicated by a Cavitary Lung Lesion in a Kidney Transplant Recipient. Case Rep Nephrol Dial 2021; 11:195-203. [PMID: 34327223 PMCID: PMC8299386 DOI: 10.1159/000516401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/04/2021] [Indexed: 02/03/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon life-threatening condition caused by an uncontrolled immunological response. It can develop secondary to malignancies, infections, systemic diseases, and immunosuppression. Multiple risk factors may present in kidney transplant recipients; however, the cases of HLH in this population have been described sparsely. We report a case of a 39-year-old female kidney transplant recipient who presented to the hospital nearly 3.5 years after the transplantation with general malaise, recent history of weight loss, fevers, and persistent anemia. Laboratory tests showed pancytopenia, hyperferritinemia, hypertriglyceridemia, and increased activity of lactate dehydrogenase. A bone marrow aspiration revealed hemophagocytosis, which led to the diagnosis of HLH. Therapy consisting of high-dose steroids and plasma exchanges was administered, resulting in a significant improvement of blood count parameters and the patient's general condition. While searching for the triggering disease, a single cavitary lesion in the right lung was revealed in a chest radiograph. Computed tomography scan, bronchoscopy, and additional laboratory testing did not reveal a definitive cause of the lesion. We suspect that the lesion may be a consequence of HLH. The patient was disqualified from thoracic surgery due to multiple comorbidities. Even though HLH is a rare condition, it should be taken into consideration in a kidney transplant patient presenting with unspecific symptoms accompanied by a bicytopenia. It has an unpredictable course that often results in serious complications. Thus close follow-up of the patient and a wide array of imaging and laboratory tests remain crucial.
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Affiliation(s)
- Katarzyna Muras-Szwedziak
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Lodz, Poland
| | - Maciej Tylski
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Lodz, Poland
| | - Anna Masajtis-Zagajewska
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Lodz, Poland
| | - Michał Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Lodz, Poland
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30
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Widjaja G, Turki Jalil A, Sulaiman Rahman H, Kamal Abdelbasset W, Bokov DO, Suksatan W, Ghaebi M, Marofi F, Gholizadeh Navashenaq J, Jadidi-Niaragh F, Ahmadi M. Humoral immune mechanisms involved in protective and pathological immunity during COVID-19. Hum Immunol 2021; 82:733-745. [PMID: 34229864 PMCID: PMC8245343 DOI: 10.1016/j.humimm.2021.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/13/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022]
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 is associated with excessive inflammation, as a main reason for severe condition and death. Increased inflammatory cytokines and humoral response to SARS-CoV-2 correlate with COVID-19 immunity and pathogenesis. Importantly, the levels of pro-inflammatory cytokines that increase profoundly in systemic circulation appear as part of the clinical pictures of two overlapping conditions, sepsis and the hemophagocytic syndromes. Both conditions can develop lethal inflammatory responses that lead to tissue damage, however, in many patients hemophagocytic lymphohistiocytosis (HLH) can be differentiated from sepsis. This is a key issue because the life-saving aggressive immunosuppressive treatment, required in the HLH therapy, is absent in sepsis guidelines. This paper aims to describe the pathophysiology and clinical relevance of these distinct entities in the course of COVID-19 that resemble sepsis and further highlights two effector arms of the humoral immune response (inflammatory cytokine and immunoglobulin production) during COVID-19 infection.
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Affiliation(s)
| | | | - Heshu Sulaiman Rahman
- College of Medicine, University of Sulaimani, Sulaimaniyah, Iraq; Department of Medical Laboratory Sciences, Komar University of Science and Technology, Chaq-Chaq Qularaise, Sulaimaniyah, Iraq
| | - Walid Kamal Abdelbasset
- Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia; Department of Physical Therapy, Kasr Al-Aini Hospital, Cairo University, Giza, Egypt
| | - Dmitry O Bokov
- Sechenov First Moscow State Medical University, 8 Trubetskaya St., bldg. 2, Moscow 119991, Russian Federation
| | - Wanich Suksatan
- Faculty of Nursing, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Mahnaz Ghaebi
- Department of Immunology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Faroogh Marofi
- Department of Hematology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Majid Ahmadi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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A Previously Healthy Policeman with Persistent Fevers, Pulmonary Infiltrates, and Multiorgan Failure. Ann Am Thorac Soc 2021; 17:1154-1157. [PMID: 32870061 DOI: 10.1513/annalsats.202004-392cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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32
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Treatment and Mortality of Hemophagocytic Lymphohistiocytosis in Adult Critically Ill Patients: A Systematic Review With Pooled Analysis. Crit Care Med 2021; 48:e1137-e1146. [PMID: 32947471 DOI: 10.1097/ccm.0000000000004581] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis is a cytokine release syndrome caused by uncontrolled immune activation resulting in multiple organ failure and death. In this systematic review, we aimed to analyze triggers, various treatment modalities, and mortality in critically ill adult hemophagocytic lymphohistiocytosis patients. DATA SOURCES MEDLINE database (PubMed) at October 20, 2019. STUDY SELECTION Studies and case series of patients greater than or equal to 18 years old, of whom at least one had to be diagnosed with hemophagocytic lymphohistiocytosis and admitted to an ICU. DATA EXTRACTION Source data of studies and case series were summarized and analyzed on an individual basis. Multivariable logistic regression analysis was performed adjusting for age, sex, and trigger groups. Each single treatment agent was entered as a dichotomous variable to determine treatments associated with survival, regardless if given alone or in combination. DATA SYNTHESIS In total, 661 patients from 65 studies and case series were included. Overall mortality was 57.8%. Infections were the most frequent trigger (49.9%), followed by malignancies (28.0%), autoimmune diseases (12.1%), unknown triggers (9.4%), and drugs (0.6%). Treatment with IV immunoglobulins was associated with improved survival (odds ratio, 0.548; 95% CI, 0.337-0.891; p = 0.015), while treatment with cyclosporine was associated with increased risk of death (odds ratio, 7.571; 95% CI, 3.702-15.483; p < 0.001). Considering different trigger groups separately, same results occurred only for infection-triggered hemophagocytic lymphohistiocytosis. No information was available on disease severity and other confounding factors. CONCLUSIONS Mortality of hemophagocytic lymphohistiocytosis in the ICU is high. Most common triggers were infections. Results of survival analyses may be biased by treatment indication and disease severity. Future studies prospectively investigating treatment tailored to critically ill hemophagocytic lymphohistiocytosis patients are highly warranted.
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33
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Adult-Onset Still's Disease Presenting as Macrophage-Activation Syndrome With Critical Illness in the Third Trimester of Pregnancy: A Case Report. Crit Care Explor 2021; 3:e0440. [PMID: 34046637 PMCID: PMC8148416 DOI: 10.1097/cce.0000000000000440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Supplemental Digital Content is available in the text. BACKGROUND: We report a case of a young woman with adult-onset Still’s disease presenting as macrophage-activation syndrome complicated by shock and respiratory failure during the third trimester of pregnancy. CASE SUMMARY: A previously healthy 26-year-old woman at 35 weeks of gestation presented with 1 week of constitutional symptoms and was found to be febrile, tachycardic, and hypotensive. She delivered a healthy neonate by cesarean section. Following delivery, she had worsening hypotension and fevers despite fluid resuscitation and antibiotics, and developed progressive hypoxemia requiring up to 60% Fio2, with bilateral upper-lobe predominant opacities on chest CT. She also had laboratory derangements including anemia, thrombocytopenia, low fibrinogen, elevated ferritin, and abnormal liver chemistries. After extensive testing to exclude infections, hemolysis, and other pertinent disorders, the development of polyarthralgias and a characteristic rash fulfilled criteria for adult-onset Still’s disease complicated by macrophage-activation syndrome. Her condition improved with immunosuppressive therapy. CONCLUSION: To our knowledge, this is the first report of new-onset adult-onset Still’s disease during the third trimester of pregnancy, which presented as macrophage-activation syndrome. In the context of late pregnancy, macrophage-activation syndrome can mimic or raise concern for hemolysis, elevated liver enzymes, and low platelet syndrome and other peripartum disorders. Furthermore, the characteristic articular symptoms of adult-onset Still’s disease may be mild and/or delayed, and pulmonary involvement with severe hypoxemia can occur. Clinicians should consider this diagnosis when evaluating a pregnant patient with unexplained fever and multiorgan dysfunction.
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34
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Leptin Deficiency, Caused by Malnutrition, Makes You Susceptible to SARS-CoV-2 Infection but Could Offer Protection from Severe COVID-19. mSphere 2021; 6:6/3/e00031-21. [PMID: 33980671 PMCID: PMC8125045 DOI: 10.1128/msphere.00031-21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In much of the developing world, severe malnutrition is the most prevalent cause of immunodeficiency and affects up to 50% of the population in some impoverished communities. As yet, we do not know how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will behave in populations with immunodeficiency caused by malnourishment. In much of the developing world, severe malnutrition is the most prevalent cause of immunodeficiency and affects up to 50% of the population in some impoverished communities. As yet, we do not know how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will behave in populations with immunodeficiency caused by malnourishment. Interestingly, researchers are now speculating that, in some instances, a defective cellular immune system could paradoxically be a protective factor against severe disease in certain patients contracting SARS-CoV and SARS-CoV-2. This could be linked to the absence of T-cell activation. Based on available information presented here, it is plausible that the hyperimmune response, and subsequent cytokine storm often associated with severe coronavirus disease 2019 (COVID-19), could be “counteracted” by the defective immune response seen in individuals with malnutrition-induced leptin deficiency. In this paper, we proposed a theory that although those with malnutrition-linked leptin deficiency are at risk of SARS-CoV-2 infection, they are at lower risk of developing severe COVID-19.
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Meng M, Chen L, Zhang S, Dong X, Li W, Li R, Deng Y, Wang T, Xu Y, Liu J, Huang Y, Chen Y, Huang S, Wen Z, Zhang L, Du H, Liu Y, Annane D, Qu J, Chen D. Risk factors for secondary hemophagocytic lymphohistiocytosis in severe coronavirus disease 2019 adult patients. BMC Infect Dis 2021; 21:398. [PMID: 33926377 PMCID: PMC8084265 DOI: 10.1186/s12879-021-06094-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 04/20/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory event and a fatal complication of viral infections. Whether sHLH may also be observed in patients with a cytokine storm induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still uncertain. We aimed to determine the incidence of sHLH in severe COVID-19 patients and evaluate the underlying risk factors. METHOD Four hundred fifteen severe COVID-19 adult patients were retrospectively assessed for hemophagocytosis score (HScore). A subset of 7 patients were unable to be conclusively scored due to insufficient patient data. RESULTS In 408 patients, 41 (10.04%) had an HScore ≥169 and were characterized as "suspected sHLH positive". Compared with patients below a HScore threshold of 98, the suspected sHLH positive group had higher D-dimer, total bilirubin, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, serum creatinine, triglycerides, ferritin, interleukin-6, C-reactive protein, procalcitonin, lactate dehydrogenase, creatine kinase isoenzyme, troponin, Sequential Organ Failure Assessment (SOFA) score, while leukocyte, hemoglobin, platelets, lymphocyte, fibrinogen, pre-albumin, albumin levels were significantly lower (all P < 0.05). Multivariable logistic regression revealed that high ferritin (>1922.58 ng/mL), low platelets (<101 × 109/L) and high triglycerides (>2.28 mmol/L) were independent risk factors for suspected sHLH in COVID-19 patients. Importantly, COVID-19 patients that were suspected sHLH positive had significantly more multi-organ failure. Additionally, a high HScore (>98) was an independent predictor for mortality in COVID-19. CONCLUSIONS HScore should be measured as a prognostic biomarker in COVID-19 patients. In particular, it is important that HScore is assessed in patients with high ferritin, triglycerides and low platelets to improve the detection of suspected sHLH.
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Affiliation(s)
- Mei Meng
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Limin Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China
| | - Xuan Dong
- Tuberculosis and Respiratory Department, Wuhan Infectious Diseases Hospital, Wuhan, China
| | - Wenzhe Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ranran Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China
| | - Yunxin Deng
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Xu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanxia Huang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yizhu Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sisi Huang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China
| | - Zhenliang Wen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lidi Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hangxiang Du
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongan Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Djillali Annane
- General intensive care unit, Raymond Poincaré Hospital (APHP), Laboratory of Inflammation and Infection U1173, University of Versailles SQY/INSERM 104 bd Raymond Poincaré, 92380, Garches, France.
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. .,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Rui Jin 2nd road, Shanghai, 200025, China.
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No 197, Rui Jin 2nd road, Shanghai, 200025, China.
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Nanno S, Koh H, Okamura H, Nishimoto M, Nakashima Y, Ohsawa M, Hino M, Nakamae H. Acute fibrinous and organizing pneumonia following hemophagocytic syndrome in two adult patients with hematological malignancies. J Clin Exp Hematop 2021; 61:93-96. [PMID: 33883345 PMCID: PMC8265494 DOI: 10.3960/jslrt.20042] [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] [Indexed: 11/08/2022] Open
Abstract
Acute fibrinous and organizing pneumonia (AFOP) is a rare acute lung injury featuring pathological intra-alveolar fibrin balls and organizing pneumonia without hyaline membranes or eosinophils. AFOP forms acute and subacute patterns; the former often has a poor prognosis, whereas the latter has better survival. Secondary hemophagocytic syndrome (HPS) is a cytokine-related and potentially lethal disorder induced by various diseases, and pulmonary involvement in HPS is not rare. However, to our knowledge, no report has addressed the association between secondary HPS and AFOP development. We report two cases of subacute AFOP following HPS in hematological malignancies.
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Affiliation(s)
- Satoru Nanno
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masahiko Ohsawa
- Diagnostic pathology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
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37
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Majumder A, Sen D. An autopsy series of an oft-missed ante-mortem diagnosis: hemophagocytic lymphohistiocytosis. AUTOPSY AND CASE REPORTS 2021; 11:e2021243. [PMID: 33968822 PMCID: PMC8087375 DOI: 10.4322/acr.2021.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal syndrome resulting from a hyperactivated immune system. Diverse patient profiles and clinical presentations often result in misdiagnosis. This article describes the varied clinical presentations and autopsy findings in three patients with this entity. The etiopathogenesis of HLH, its disparate and confounding clinical features, the diagnostic criteria, and management principles are also briefly reviewed.
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Affiliation(s)
- Anusree Majumder
- Armed Forces Medical College and Command Hospital (Southern Command), Department of Pathology and Laboratory Sciences, Pune, India
| | - Debraj Sen
- Armed Forces Medical College and Command Hospital (Southern Command), Department of Radiodiagnosis and Imaging, Pune, India
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38
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Smits BM, van Montfrans J, Merrill SA, van de Corput L, van Gijn M, de Vries A, van den Bos C, Abbink F, van der Molen RG, Dors N, Lindemans C, Boelens JJ, Nierkens S. A Minimal Parameter Set Facilitating Early Decision-making in the Diagnosis of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2021; 41:1219-1228. [PMID: 33779897 PMCID: PMC8310853 DOI: 10.1007/s10875-021-01005-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 02/23/2021] [Indexed: 12/11/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune dysregulation syndrome characterized by uncontrolled immune cell activation. Timely diagnosis is important, since early treatment can improve survival rates. However, completing all assessments needed to reach ≥5 positive criteria out of the 8 HLH-2004 criteria can be time consuming and may delay timely initiation of treatment. Hence, we applied a data-driven approach to identify a minimal parameter set for early decision-making towards the initiation of HLH-specific treatment. We retrospectively evaluated 165 patients from five Dutch tertiary hospitals with suspected HLH. Sixteen pHLH (median age 0.5 years) and 70 sHLH patients (median age 8.7 years) were identified using the HLH-2004 criteria. Clustering analysis and multi-receiver operator characteristics were used to identify parameters distinctive of HLH. The presence of either increased ferritin, cytopenia in ≥2 lineages, or splenomegaly distinguished HLH from non-HLH cases with a negative predictive value of 100%. A minimal parameter set consisting of 2 major criteria (phagocytosis and splenomegaly) and 3 minor criteria (cytopenia, increased ferritin, and increased triglycerides/low fibrinogen) predicted HLH with 95% (88-99) sensitivity and 94% (86-98) specificity. This finding was replicated in an independent retrospective validation cohort of 109 US patients (n = 109). By dividing a subset of the HLH-2004 criteria into major and minor criteria, this strategy uses the evaluation of less than 5 criteria to quickly identify patients with HLH. When confirmed in a prospective setting, this approach could be of value for timely diagnosis and treatment of HLH.
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Affiliation(s)
- Bas M Smits
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Samuel A Merrill
- Division of Hematology/Oncology, West Virginia University, Morgantown, WV, USA
| | - Lisette van de Corput
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Mariëlle van Gijn
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrica de Vries
- Department of Pediatric Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Floor Abbink
- Department of Pediatric Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Renate G van der Molen
- Department of Laboratory Medicine, Laboratory for Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natasja Dors
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jaap J Boelens
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefan Nierkens
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands. .,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
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39
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NURSING INTERVENTIONS IN THE MANAGEMENT OF COVID-19-RELATED DELIRIUM IN INTENSIVE CARE UNITS: LITERATURE REVIEW. INTERNATIONAL JOURNAL OF HEALTH SERVICES RESEARCH AND POLICY 2021. [DOI: 10.33457/ijhsrp.845184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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40
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Balan S, Beauchamps L, Gonzales-Zamora JA, Vu C, Amoros A, Quiroz T, Stevenson M, Sharkey M, Andrews DM, Abbo L. Recovery does not always signal the end of the battle: A case of post SARS-CoV-2 multisystem inflammatory syndrome in an adult. IDCases 2021; 24:e01067. [PMID: 33747788 PMCID: PMC7968306 DOI: 10.1016/j.idcr.2021.e01067] [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: 12/06/2020] [Revised: 01/27/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022] Open
Abstract
We describe a case of SARS-CoV-2 post-infectious inflammatory syndrome in an adult who presented with multiorgan failure two months following his initial diagnosis of SARS-CoV-2 infection. This case highlights clinician’s early recognition of this devastating sequela and challenges in appropriate management of this patient.
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Affiliation(s)
- Shuba Balan
- Department of Medicine, Division of Infectious Diseases, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, FL, United States
| | - Laura Beauchamps
- Department of Medicine, Division of Infectious Diseases, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jose Armando Gonzales-Zamora
- Department of Medicine, Division of Infectious Diseases, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, FL, United States
| | - Christine Vu
- Jackson Memorial Hospital, Department of Pharmacy, Miami, FL, United States
| | - Annette Amoros
- Division of Infectious Diseases and Critical Care, Jackson Memorial Hospital, Miami, FL, United States
| | - Tanya Quiroz
- Division of Infectious Diseases, Jackson Memorial Hospital, Miami, FL, United States
| | - Mario Stevenson
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mark Sharkey
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, United States
| | - David M Andrews
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Lilian Abbo
- Department of Medicine, Division of Infectious Diseases, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, FL, United States.,Department of Infection Prevention and Antimicrobial Stewardship, Jackson Health System, Miami, FL, United States
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41
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Tocilizumab in patients with moderate or severe COVID-19: a randomized, controlled, open-label, multicenter trial. Front Med 2021; 15:486-494. [PMID: 33687643 PMCID: PMC7940448 DOI: 10.1007/s11684-020-0824-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/21/2022]
Abstract
Tocilizumab has been reported to attenuate the “cytokine storm” in COVID-19 patients. We attempted to verify the effectiveness and safety of tocilizumab therapy in COVID-19 and identify patients most likely to benefit from this treatment. We conducted a randomized, controlled, open-label multicenter trial among COVID-19 patients. The patients were randomly assigned in a 1:1 ratio to receive either tocilizumab in addition to standard care or standard care alone. The cure rate, changes of oxygen saturation and interference, and inflammation biomarkers were observed. Thirty-three patients were randomized to the tocilizumab group, and 32 patients to the control group. The cure rate in the tocilizumab group was higher than that in the control group, but the difference was not statistically significant (94.12% vs. 87.10%, rate difference 95% CI–7.19%–21.23%, P = 0.4133). The improvement in hypoxia for the tocilizumab group was higher from day 4 onward and statistically significant from day 12 (P = 0.0359). In moderate disease patients with bilateral pulmonary lesions, the hypoxia ameliorated earlier after tocilizumab treatment, and less patients (1/12, 8.33%) needed an increase of inhaled oxygen concentration compared with the controls (4/6, 66.67%; rate difference 95% CI–99.17% to–17.50%, P = 0.0217). No severe adverse events occurred. More mild temporary adverse events were recorded in tocilizumab recipients (20/34, 58.82%) than the controls (4/31, 12.90%). Tocilizumab can improve hypoxia without unacceptable side effect profile and significant influences on the time virus load becomes negative. For patients with bilateral pulmonary lesions and elevated IL-6 levels, tocilizumab could be recommended to improve outcome.
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42
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Li D, Hu J, Li D, Yang W, Yin SF, Qiu R. Reviews on Biological Activity, Clinical Trial and Synthesis Progress of Small Molecules for the Treatment of COVID-19. Top Curr Chem (Cham) 2021; 379:4. [PMID: 33428032 PMCID: PMC7797499 DOI: 10.1007/s41061-020-00318-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/27/2020] [Indexed: 02/07/2023]
Abstract
COVID-19 has broken out rapidly in nearly all countries worldwide, and has blossomed into a pandemic. Since the beginning of the spread of COVID-19, many scientists have been cooperating to study a vast array of old drugs and new clinical trial drugs to discover potent drugs with anti-COVID-19 activity, including antiviral drugs, antimalarial drugs, immunosuppressants, Chinese medicines, Mpro inhibitors, JAK inhibitors, etc. The most commonly used drugs are antiviral compounds, antimalarial drugs and JAK inhibitors. In this review, we summarize mainly the antimalarial drugs chloroquine and hydroxychloroquine, the antiviral drugs Favipiravir and Remdesivir, and JAK inhibitor Ruxolitinib, discussing their biological activities, clinical trials and synthesis progress.
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Affiliation(s)
- Dingzhong Li
- State Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry and Chemical Engineering, Hunan University, Changsha, 410082, People's Republic of China
| | - Jianbing Hu
- State Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry and Chemical Engineering, Hunan University, Changsha, 410082, People's Republic of China.
| | - Dian Li
- Department of Modern Economy and Trade, Hunan Vocational College of Engineering, Changsha, 410151, People's Republic of China
| | - Weijun Yang
- State Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry and Chemical Engineering, Hunan University, Changsha, 410082, People's Republic of China.
| | - Shuang-Feng Yin
- State Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry and Chemical Engineering, Hunan University, Changsha, 410082, People's Republic of China
| | - Renhua Qiu
- State Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry and Chemical Engineering, Hunan University, Changsha, 410082, People's Republic of China.
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Yasmin H, Saha S, Butt MT, Modi RK, George AJT, Kishore U. SARS-CoV-2: Pathogenic Mechanisms and Host Immune Response. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1313:99-134. [PMID: 34661893 DOI: 10.1007/978-3-030-67452-6_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped, positive-sense RNA coronavirus responsible for the COVID-19 pandemic. Since December 2019, coronavirus disease 2019 (COVID-19) has affected more than 127 million people, 2.7 million deaths globally (as per WHO dashboard, dated 31 March, 2020), the virus is capable of transmitting from human to human via inhalation of infected respiratory droplets or aerosols or contact with infected fomites. Clinically, patients with COVID-19 present with severe respiratory distress syndrome, which is very similar to the presentation of other respiratory viral infections. A huge variation in the host response exists, with the resulting symptoms varying from mild to moderate. Comorbidities such as cardiovascular disease, hypertension, diabetes, coagulation dysfunction, stroke, malignant tumor and multiple organ dysfunction syndrome, as well as age and sex, are associated with severe COVID-19 cases. So far, no targeted therapies have been developed to treat this disease and existing drugs are being investigated for repurposing. This chapter discusses the epidemiology, clinical features of COVID-19, pathogenesis and the innate and adaptive immune response mounted by the host to the SARS-CoV-2 infection. A deeper understanding of the host-pathogen interaction is fundamental to the development of a vaccine.
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Affiliation(s)
- Hadida Yasmin
- Immunology and Cell Biology Laboratory, Department of Zoology, Cooch Behar Panchanan Barma University, Cooch Behar, West Bengal, India
| | - Sudipta Saha
- Amity Institute of Physiology and Allied Sciences, Amity University Campus, Noida, Uttar Pradesh, India
| | - Mariam Tariq Butt
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
| | - Rishab Kumar Modi
- Immunology and Cell Biology Laboratory, Department of Zoology, Cooch Behar Panchanan Barma University, Cooch Behar, West Bengal, India
| | - Andrew J T George
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Uday Kishore
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK.
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Olaleye O, Titilope O, Moses O. Possible health benefits of polyphenols in neurological disorders associated with COVID-19. ACTA FACULTATIS MEDICAE NAISSENSIS 2021. [DOI: 10.5937/afmnai38-30190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Novel Coronavirus disease 2019 (COVID-19) represents an emergent global health burden that has challenged the health systems worldwide. Since its sudden upsurge in 2019, many COVID-19 patients have exhibited neurological symptoms and complications. Till now, there is no known effective established drug against the highly contagious COVID-19 infection despite the frightening associated mortality rate. This article aims to present the mechanism of action of coronavirus-2 (SARS-CoV-2), the clinical neurological manifestations displayed by COVID-19 patients, and present polyphenols with neuroprotective ability that can offer beneficial effects against COVID-19-mediated neuropathology. Reports from COVID-19 clinical studies, case reports, and other related literature were evaluated for this review. Neurological complications of COVID-19 include anosmia, acute cerebrovascular disease, acute disseminated post-infectious encephalomyelitis, encephalitis, etc. Also, SARS-CoV-2 sould be a neurotropic vіruѕ due to its iѕolatіon from serebroѕrіnal fluіd. Multіrle neurologіsal damages displayed by COVID-19 patients might be due to hyperinflammation associated with SARS-CoV-2 infections. Resveratrol, kolaviron, quercetin and apigenin are polyphenols with proven anti-inflammatory and therapeutic properties that can extenuate the adverse effects of COVID-19. These polyphenols have been documented to suppress c-Jun N-terminal kinase (JNK), phosphoinositide-3-kinase (PI3-K), extrasellularѕіgnal-regulated kinase (ERK), nuclear factor kappa-light-chain-enhancer of activated B-cells (NF-kB) and mіtogen-astіvated protein kіnaѕe (MAPK) pathways which are essential in the pathogenesis of COVID-19. They also showed significant inhibitory activities against SARS-CoV-2 proteins. Taken together, these polyphenols may offer neuroprotective benefits against COVID-19 mediated neuropathology via modulation of the pathogenic pathways.
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45
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Bajracharya S, Shrestha A, Rajbhandari B. Symptoms of COVID-19 Confirmed Cases Presenting to Emergency Department in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2020; 58:1041-1045. [PMID: 34506378 PMCID: PMC8028528 DOI: 10.31729/jnma.5519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Clinical presentation of the patient with COVID-19 in an emergency department is very important. The proper assessment of the symptom allows correct intervention. So, this study is conducted specifically to find out the clinical spectrum of the patient on presentation to the emergency department. METHODS This was a cross-sectional descriptive study. A retrospective analysis of patient records was done. There were 258 COVID-19 positive cases admission from 13th April to 13th August 2020. Out of these cases, 57 cases were excluded as they did not have respiratory symptoms but were admitted for other medical conditions. So, 201 symptomatic patients were analyzed in this study. Symptoms of all patients with the confirmed diagnosis of COVID-19 admitted from the emergency department were analyzed. Data entry was done in an excel sheet and presenting symptoms of COVID-19 positive patients were described along with their comorbid conditions. RESULTS Two hundred and one symptomatic patients were analyzed in this study. The mean age of study population was 37.9 years (median 37) with a minimum age of 2 months and a maximum age of 83 years. There were 114 (56.7%) male and 87 (43.3%) female; 109 (54.2%) patients were from outside the and 92 (45.8%) were from inside of Kathmandu Valley. The most common presenting symptom was fever 131 (65.2%) and cardiovascular condition including hypertension was the most common comorbid condition. CONCLUSIONS Fever was the most common symptom of the patient presenting to the COVID19 emergency of our hospital. Moreover, fever needs to be analyzed carefully in terms of its onset total duration and associated cough, and underlying comorbid condition.
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Affiliation(s)
- Sumana Bajracharya
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ashis Shrestha
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Bibek Rajbhandari
- Department of General Practice and Emergency Medicine, Nepal Police Hospital, Kathmandu, Nepal
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Masmouei B, Harorani M, Bazrafshan MR, Karimi Z. COVID-19: Hyperinflammatory Syndrome and Hemoadsorption with CytoSorb. Blood Purif 2020; 50:976-978. [PMID: 33326959 PMCID: PMC7801968 DOI: 10.1159/000512199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 10/02/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Behnam Masmouei
- Department of Nursing, School of Nursing Hazrat Zahra (P.B.U.H) Abadeh, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Mehdi Harorani
- Department of Nursing, School of Nursing and Midwifery, Arak University of Medical Sciences, Arak, Iran
| | - Mohammad-Rafi Bazrafshan
- Department of Nursing, School of Nursing, Larestan University of Medical Sciences, Larestan, Iran
| | - Zahra Karimi
- Clinical Nurse, Shiraz University of Medical Sciences, Shiraz, Iran
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47
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Cabrera-Marante O, de Frías ER, Pleguezuelo DE, Allende LM, Serrano A, Laguna-Goya R, Mancebo ME, Talayero P, Álvarez-Vallina L, Morales P, Castro-Panete MJ, Paz-Artal E. Perforin gene variant A91V in young patients with severe COVID-19. Haematologica 2020; 105:2844-2846. [PMID: 33256384 PMCID: PMC7716361 DOI: 10.3324/haematol.2020.260307] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Oscar Cabrera-Marante
- Servicio de Inmunología, Instituto de Investigaciones Sanitarias, Hospital 12 de Octubre, Madrid, Spain
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48
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Kappert K, Jahić A, Tauber R. Assessment of serum ferritin as a biomarker in COVID-19: bystander or participant? Insights by comparison with other infectious and non-infectious diseases. Biomarkers 2020; 25:616-625. [PMID: 32700561 DOI: 10.1080/1354750x.2020.1797880] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The 2019 coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus has an impact on all aspects of patient care. Serum ferritin generally represents a biomarker of choice when iron deficiency is suspected. However, ferritin is also an acute-phase-protein exhibiting elevated serum concentration in various inflammatory diseases. Here we focus on the role of serum ferritin for diagnostic and clinical management of patients with COVID-19 in comparison with other infectious and non-infectious diseases. METHODS We examined scientific articles listed in PubMed reporting on ferritin in various infectious and non-infectious diseases. We then compared these results with nine current COVID-19 ferritin reports published in 2020. RESULTS Several non-infectious, as well as non-COVID-19 infectious diseases, are characterised by a partly dramatic elevation of serum ferritin levels. All COVID-19 studies published between February and May 2020, which documented laboratory serum ferritin, indicate ferritin as a biomarker of COVID-19 severity in hospitalised patients. CONCLUSIONS Serum ferritin may be considered both a prognostic and stratifying biomarker that can also contribute to therapeutic decision-making concerning patients with COVID-19. It should be emphasised, however, that most scientific reports refer to cohorts in the Asian region. Further validation in other cohorts is urgently required.
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Affiliation(s)
- Kai Kappert
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Amir Jahić
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Rudolf Tauber
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
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49
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Spanopoulou C, Kassimos D, Cassimos D. Potential Role of Anti-Complement Agents in the Treatment of COVID-19-Related ARDS. Mediterr J Rheumatol 2020; 31:304-305. [PMID: 33196010 PMCID: PMC7656134 DOI: 10.31138/mjr.31.3.304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Dimitrios Kassimos
- Paediatric Department, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Cassimos
- Paediatric Clinic, General University Hospital of Alexandroupolis, Alexandroupolis, Greece
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50
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Horowitz RI, Freeman PR. Three novel prevention, diagnostic, and treatment options for COVID-19 urgently necessitating controlled randomized trials. Med Hypotheses 2020; 143:109851. [PMID: 32534175 PMCID: PMC7242962 DOI: 10.1016/j.mehy.2020.109851] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/17/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Asymptomatic or minimally symptomatic infection with COVID-19 can result in silent transmission to large numbers of individuals, resulting in expansion of the pandemic with a global increase in morbidity and mortality. New ways of screening the general population for COVID-19 are urgently needed along with novel effective prevention and treatment strategies. HYPOTHESIS A hypothetical three-part prevention, diagnostic, and treatment approach based on an up-to-date scientific literature review for COVID-19 is proposed. Regarding diagnosis, a validated screening questionnaire and digital app for COVID-19 could help identify individuals who are at risk of transmitting the disease, as well as those at highest risk for poor clinical outcomes. Global implementation and online tracking of vital signs and scored questionnaires that are statistically validated would help health authorities properly allocate essential health care resources to test and isolate those at highest risk for transmission and poor outcomes. Second, regarding prevention, no validated protocols except for physical distancing, hand washing, and isolation exist, and recently ivermectin has been published to have anti-viral properties against COVID-19. A randomized trial of ivermectin, and/or nutraceuticals that have been published to support immune function including glutathione, vitamin C, zinc, and immunomodulatory supplements (3,6 Beta glucan) could be beneficial in preventing transmission or lessening symptomatology but requires statistical validation. Third, concerning treatment, COVID-19 induced inflammation and "cytokine storm syndrome" with hemophagocytic lymphohistiocytosis (HLH)/Macrophage Activation Syndrome (MAS) have resulted in extreme morbidity and mortality in those with certain comorbidities, secondary to "acute respiratory distress syndrome" (ARDS) and multiorgan dysfunction with disseminated intravascular coagulation (DIC). Deficiency in red blood cell, serum and alveolar glutathione has been published in the medical literature for ARDS, as well as viral and bacterial pneumonias, resulting from increased levels of free radical/oxidative stress. A randomized controlled trial of blocking NF-κB and cytokine formation using glutathione precursors (N-acetyl-cysteine [NAC] and alpha lipoic acid) and PO/IV glutathione with associated anti-viral effects should be performed, along with an evaluation of Nrf2 activators (curcumin, sulforaphane glucosinolate) which have been scientifically proven to lower inflammation. Since high mortality rates from sepsis induced DIC due to COVID-19 infection has also been associated with thrombotic events and elevated levels of D-dimer, randomized controlled trials of using anticoagulant therapy with heparin is urgently required. This is especially important in patients on ventilators who have met certain sepsis induced coagulopathy (SIC) criteria. The use of acetazolamide with or without sildenafil also needs to be explored with or without heparin, since increased oxygen delivery to vital organs through prevention of thrombosis/pulmonary emboli along with carbonic anhydrase inhibition may help increase oxygenation and prevent adverse clinical outcomes. CONCLUSION AND IMPLICATIONS A three-part prevention, diagnostic, and treatment plan is proposed for addressing the severe complications of COVID-19. Digital monitoring of symptoms to clinically diagnose early exposure and response to treatment; prevention with ivermectin as well as nutritional therapies that support a healthy immune response; treatment with anti-inflammatory therapies that block NF-κB and activate Nrf2 pathways, as well as novel therapies that address COVID-19 pneumonia and ARDS with DIC including anticoagulation and/or novel respiratory therapies with or without acetazolamide and sildenafil. These three broad-based interventions urgently need to be subjected to randomized, controlled trials.
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Affiliation(s)
- Richard I Horowitz
- HHS Babesia and Tickborne Pathogen Subcommittee, Washington, D.C. 20201, USA; Hudson Valley Healing Arts Center, 4232 Albany Post Road, Hyde Park, NY 12538, USA.
| | - Phyllis R Freeman
- Hudson Valley Healing Arts Center, 4232 Albany Post Road, Hyde Park, NY 12538, USA
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