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Vastert SJ, Canny SP, Canna SW, Schneider R, Mellins ED. Cytokine Storm Syndrome Associated with Systemic Juvenile Idiopathic Arthritis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:323-353. [PMID: 39117825 DOI: 10.1007/978-3-031-59815-9_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
The cytokine storm syndrome (CSS) associated with systemic juvenile idiopathic arthritis (sJIA) has widely been referred to as macrophage activation syndrome (MAS). In this chapter, we use the term sJIA-associated CSS (sJIA-CSS) when referring to this syndrome and use the term MAS when referencing publications that specifically report on sJIA-associated MAS.
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Affiliation(s)
- Sebastiaan J Vastert
- Department of Paediatric Rheumatology & Immunology and Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Susan P Canny
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Scott W Canna
- Department of Pediatrics and Institute for Immunology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rayfel Schneider
- Department of Paediatrics, University of Toronto and The Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth D Mellins
- Divisions of Human Gene Therapy and Allergy, Immunology & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford Program in Immunology, Stanford University School of Medicine, Stanford, CA, USA.
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2
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Chang Y, Shan X, Ge Y. Macrophage activation syndrome in juvenile dermatomyositis: a case report and a comprehensive review of the literature. Pediatr Rheumatol Online J 2023; 21:106. [PMID: 37735702 PMCID: PMC10515226 DOI: 10.1186/s12969-023-00893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a severe and life-threatening syndrome associated with autoimmune diseases. The coexistence of MAS and juvenile dermatomyositis (JDM) is not well reported. This report describes a case of JDM with MAS and summarizes the clinical characteristics and prognosis of MAS in patients with JDM. CASE PRESENTATION The patient was a 15-year-old female with JDM, presenting with heliotrope rash, muscle weakness, increased muscle enzyme, anti-nuclear matrix protein 2 (NXP2) antibody, and muscle biopsy consistent with JDM. The patient developed fever, cytopenia, and hyperferritinemia three months after the first manifestations. Hemophagocytosis was found in the bone marrow. The final diagnosis was JDM combined with MAS. Despite intensive treatment, the patient died of MAS. By reviewing the literature, we found 17 similar cases. Together with the present case, 18 patients were identified, the median age of disease onset was 13.5 years, and male to female ratio was 1.25: 1. Nine out of 16 (56.3%) patients were complicated with interstitial lung disease (ILD). The median time interval between JDM onset and MAS diagnosis was 9 weeks. At the onset of MAS, all (100%) patients had elevated levels of ferritin and serum liver enzymes. Among 18 patients, 14 (77.8%) had fever, 14/17 (82.4%) had cytopenia, 11/11 (100%) had hepatosplenomegaly, and 13/14 (92.9%) had hemophagocytosis. Five (27.8%) patients showed central nervous system (CNS) involvement. The mortality of MAS rate of in patients with JDM was 16.7%, despite various treatment methods. CONCLUSION . The coexistence of JDM and MAS is underestimated with increased mortality. Hepatosplenomegaly and increased serum levels of ferritin in patients with JDM should raise clinical suspicion for MAS.
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Affiliation(s)
- Yong Chang
- Department of Rheumatology, Tianshui Hospital of Traditional Chinese Medicine, Tianshui, China
| | - Xueyan Shan
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China.
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3
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Chen S, Zhang C, Chen D, Dong L, Chang T, Tang ZH. Advances in attractive therapeutic approach for macrophage activation syndrome in COVID-19. Front Immunol 2023; 14:1200289. [PMID: 37483597 PMCID: PMC10358730 DOI: 10.3389/fimmu.2023.1200289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Nowadays, people have relaxed their vigilance against COVID-19 due to its declining infection numbers and attenuated virulence. However, COVID-19 still needs to be concern due to its emerging variants, the relaxation of restrictions as well as breakthrough infections. During the period of the COVID-19 infection, the imbalanced and hyper-responsive immune system plays a critical role in its pathogenesis. Macrophage Activation Syndrome (MAS) is a fatal complication of immune system disease, which is caused by the excessive activation and proliferation of macrophages and cytotoxic T cells (CTL). COVID-19-related hyperinflammation shares common clinical features with the above MAS symptoms, such as hypercytokinemia, hyperferritinemia, and coagulopathy. In MAS, immune exhaustion or defective anti-viral responses leads to the inadequate cytolytic capacity of CTL which contributes to prolonged interaction between CTL, APCs and macrophages. It is possible that the same process also occurred in COVID-19 patients, and further led to a cytokine storm confined to the lungs. It is associated with the poor prognosis of severe patients such as multiple organ failure and even death. The main difference of cytokine storm is that in COVID-19 pneumonia is mainly the specific damage of the lung, while in MAS is easy to develop into a systemic. The attractive therapeutic approach to prevent MAS in COVID-19 mainly includes antiviral, antibiotics, convalescent plasma (CP) therapy and hemadsorption, extensive immunosuppressive agents, and cytokine-targeted therapies. Here, we discuss the role of the therapeutic approaches mentioned above in the two diseases. And we found that the treatment effect of the same therapeutic approach is different.
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Affiliation(s)
- Shunyao Chen
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cong Zhang
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Deng Chen
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Dong
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Teding Chang
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhao-Hui Tang
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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4
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Ambler WG, Nanda K, Onel KB, Shenoi S. Refractory systemic onset juvenile idiopathic arthritis: current challenges and future perspectives. Ann Med 2022; 54:1839-1850. [PMID: 35786149 PMCID: PMC9258439 DOI: 10.1080/07853890.2022.2095431] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is a rare disease with distinct features not seen in other categories of juvenile idiopathic arthritis. In recent years, advances in the understanding of disease immunopathogenesis have led to improved targeted therapies with significant improvement in patient outcomes. Despite these advances, there remain subsets of SJIA with refractory disease and severe disease-associated complications. This review highlights existing options for treatment of refractory SJIA and explores potential future therapeutics for refractory disease.Key Points:Despite targeted Interleukin IL-1 and IL-6 inhibitors a subset of SJIA remains refractory to therapy. About 1 in 7 SJIA patients will be refractory to targeted IL-1 or IL-6 therapy.There is no current agreed upon definition for refractory SJIA and we propose in this review that refractory SJIA is presence of active systemic or arthritic features despite treatment with anti-IL-1 or anti-IL-6 therapy or disease requiring glucocorticoids for control beyond 6 months.SJIA disease associated complications include presence of associated macrophage activation syndrome (MAS), interstitial lung disease (ILD) or amyloidosis and management of each differs.Refractory SJIA treatment options currently include additional conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS), biologic (bDMARDS), combination biologic therapy, targeted synthetic (tsDMARDS) or other immunomodulatory therapies.
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Affiliation(s)
- William G Ambler
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Kabita Nanda
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, WA, USA
| | - Karen Brandt Onel
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, WA, USA
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5
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Zhang HQ, Yang SW, Fu YC, Chen MC, Yang CH, Yang MH, Liu XD, He QN, Jiang H, Zhao MY. Cytokine storm and targeted therapy in hemophagocytic lymphohistiocytosis. Immunol Res 2022; 70:566-577. [PMID: 35819695 DOI: 10.1007/s12026-022-09285-w] [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: 03/21/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening systemic hyperinflammatory syndrome. The central pathogenesis is an explosive cytokine storm characterized by a significant increase in proinflammatory cytokines, including IL-1β, IL-6, IL-18, IFN-γ, and TNF-α. Meanwhile, negative regulatory factors, such as IL-10 and TGF-β, are also related to the production of HLH. Exploring the specific mechanism of cytokine storms could provide ideas regarding targeted therapy, which could be helpful for early treatment to reduce the mortality of HLH. Although some research has focused on the advantages of targeted therapies, there is still a lack of a comprehensive discourse. This article attempts to summarize the mechanisms of action of various cytokines and provide a therapeutic overview of the current targeted therapies for HLH.
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Affiliation(s)
- Han-Qi Zhang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.,Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Si-Wei Yang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.,Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Yi-Cheng Fu
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Ming-Cong Chen
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Cheng-Hao Yang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.,Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Ming-Hua Yang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Xiao-Dan Liu
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, Guangdong, China
| | - Qing-Nan He
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, 510623, Guangdong, China.
| | - Ming-Yi Zhao
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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6
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Yamamoto M, Sato M, Onishi Y, Sasahara Y, Sano H, Masuko M, Nakamae H, Matsuoka K, Ara T, Washio K, Onizuka M, Watanabe K, Takahashi Y, Hirakawa T, Nishio M, Sakashita C, Kobayashi T, Sawada A, Ichinohe T, Fukuda T, Hashii Y, Atsuta Y, Arai A. Registry data analysis of hematopoietic stem cell transplantation on systemic chronic active Epstein-Barr virus infection patients in Japan. Am J Hematol 2022; 97:780-790. [PMID: 35312194 DOI: 10.1002/ajh.26544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 12/27/2022]
Abstract
The effects of allogeneic hematopoietic stem cell transplantation (allo-HSCT) on systemic chronic active Epstein-Barr virus infection (sCAEBV) are yet to be analyzed in a large number of patients. Using the Japanese registry database, Transplant Registry Unification Management Program, we investigated the outcomes of 102 sCAEBV patients who underwent allo-HSCT. The median age at HSCT was 21 years, and the three-year overall survival (3-year OS) rate was 72.5%. Of the 90 patients whose viral load after allo-HSCT was evaluated, 56 (62.2%) achieved a virological complete response, defined by the complete resolution of disease activity with a significant decrease in EBV-DNA in peripheral blood. The multivariate Cox proportional hazard model indicated that advanced age, in adolescents and young adults (AYA) (age, 15-39) and adults (age, ≥40 years) was a risk factor of poor OS. The hazard ratios (HRs) of the AYA and adult groups were 10.87 (95% confidence interval [CI]: 1.98-59.56, p = .006) and 15.93 (95% CI: 2.45-103.8, p = .004), respectively. Disease activity (HR 5.74), elevated soluble IL-2 receptor (sIL-2R) (≥ median, 691 U/mL) at HSCT (HR 6.93), and conditioning without radiotherapy (HR 3.53) were also independently associated with poor survival. Notably, 79% of radiotherapy doses were less than 6 Gy. Regardless of the presence of hemophagocytic lymphohistiocytosis, the group with a high sIL-2R level (≥2000 U/mL) showed a poorer prognosis. Although allo-HSCT is the only curative therapy for sCAEBV, treatment strategies need to be improved for high-risk patients, especially those with high levels of sIL-2R.
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Affiliation(s)
- Masahide Yamamoto
- Department of Hematology Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Maho Sato
- Department of Hematology/Oncology Osaka Women's and Children's Hospital Izumi Japan
| | - Yasushi Onishi
- Department of Hematology Tohoku University Hospital Sendai Japan
| | - Yoji Sasahara
- Department of Pediatrics Tohoku University Hospital Sendai Japan
| | - Hideki Sano
- Department of Pediatric Oncology Fukushima Medical University Hospital Fukushima Japan
| | - Masayoshi Masuko
- Division of Stem Cell Transplantation Niigata University Medical and Dental Hospital Niigata Japan
| | | | - Ken‐ichi Matsuoka
- Department of Hematology and Oncology Okayama University Hospital Okayama Japan
| | - Takahide Ara
- Department of Hematology Hokkaido University Hospital Sapporo Japan
| | - Kana Washio
- Department of Pediatrics Okayama University Hospital Okayama Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology Tokai University School of Medicine Isehara Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology Shizuoka Children's Hospital Shizuoka Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics Nagoya University Graduate School of Medicine Nagoya Japan
| | - Tsuneaki Hirakawa
- Division of Hematology and Oncology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Miwako Nishio
- Department of Laboratory Molecular Genetics of Hematology, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Chizuko Sakashita
- Department of Hematology Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Tohru Kobayashi
- Clinical Research Center, National Center for Child Health and Development Tokyo Japan
| | - Akihisa Sawada
- Department of Hematology/Oncology Osaka Women's and Children's Hospital Izumi Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology Research Institute for Radiation Biology and Medicine, Hiroshima University Higashihiroshima Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division National Cancer Center Hospital Tokyo Japan
| | - Yoshiko Hashii
- Cancer Immunotherapy/Pediatrics Osaka University Graduate School of Medicine Osaka Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation Nagoya Japan
- Department of Registry Science for Transplant and Cellular Therapy Aichi Medical University School of Medicine Nagakute Japan
| | - Ayako Arai
- Division of Hematology and Oncology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
- Department of Hematological Therapeutics, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University (TMDU) Tokyo Japan
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7
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Ding Y, Ge Y. Anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis complicated with macrophage activation syndrome. Ther Adv Chronic Dis 2022; 13:20406223221098128. [PMID: 35586303 PMCID: PMC9109495 DOI: 10.1177/20406223221098128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/13/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody-positive
dermatomyositis (DM) has low survival rate, whereas macrophage activation
syndrome (MAS) is a severe and life-threatening syndrome associated with
autoimmune diseases. Their coexistence is very rare. This study aimed to
describe the prevalence, clinical characteristics, and outcomes of anti-MDA5
antibodies-positive DM patients complicated with MAS. Methods: In this retrospective study, we enrolled DM patients with anti-MDA5
antibodies, who were hospitalized between 2016 and 2020 and included
patients diagnosed with MAS. Results: We identified four (2%) DM patients with anti-MDA5 antibodies. They were
females with interstitial lung disease (ILD). The level of aspartate
aminotransferase (AST), lactate dehydrogenase (LDH), and ferritin were
significantly higher in the MAS group than those without MAS
(p < 0.05). Patients with MAS were significantly
more likely to develop a dysphagia (p = 0.012). Literature
review revealed eight similar cases. Together with the present study, we
identified 12 patients complicated with ILD. The median age of disease onset
was 52 years with a male to female ratio of 1:6. The median duration between
DM onset and MAS diagnosis was 3 months. The mortality of MAS in anti-MDA5
antibody-positive DM was 50%. Patients who died were older than those who
survived (56.7 years versus 35.5 years;
p = 0.015). Conclusions: MAS was rare in anti-MDA5 antibody-positive DM. The higher the level of AST,
LDH, and ferritin, the greater the risk of MAS. They were associated with
high mortality rates, particularly in older patients.
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Affiliation(s)
- Yukang Ding
- Department of Rheumatology, The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029 Beijing, China
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Shiga T, Nozaki Y, Tomita D, Kishimoto K, Hirooka Y, Kinoshita K, Funauchi M, Matsumura I. Usefulness of Interleukin-18 as a Diagnostic Biomarker to Differentiate Adult-Onset Still's Disease With/Without Macrophage Activation Syndrome From Other Secondary Hemophagocytic Lymphohistiocytosis in Adults. Front Immunol 2021; 12:750114. [PMID: 34691064 PMCID: PMC8533049 DOI: 10.3389/fimmu.2021.750114] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022] Open
Abstract
Background Interleukin (IL)-18 is markedly elevated in systemic inflammatory diseases that cause the ‘cytokine storm’ such as adult-onset Still’s disease (AOSD) and hemophagocytic lymphohistiocytosis (HLH). The differences in IL-18 between AOSD and HLH, especially in adults, is uncertain. Macrophage activation syndrome (MAS), a form of secondary HLH, is often difficult to differentiate cases of AOSD that include MAS from other secondary HLH. In this case-control study, we investigated whether serum IL-18 levels could be a useful biomarker for the differential diagnosis of AOSD with or without MAS (AOSD group) and other secondary HLH in adults (adult HLH group). Patients and Methods We enrolled 46 patients diagnosed with AOSD including 9 patients with MAS and 31 patients in the adult HLH group, which excluded AOSD-associated MAS. The clinical features and laboratory data were compared between the AOSD and adult HLH groups. In addition, we subdivided the AOSD group (with or without MAS) and the adult HLH group (whether lymphoma-associated or not) and compared the four groups. A logistic regression analysis was used to identify factors with high efficacy in differentiating the two groups, followed by a receiver operating characteristic (ROC) curve analysis to evaluate the differential diagnostic ability of IL-18. We analyzed the correlation between IL-18 and various laboratory parameters in the AOSD group. Results Serum IL-18 levels of patients in the AOSD groups were significantly higher than those of the adult HLH groups, and were closely correlated with ferritin, soluble interleukin-2 receptor (sIL-2R), and other laboratory data. Univariate and multivariate logistic regression analyses revealed that IL-18, sIL-2R, and ‘arthralgia or arthritis’ are independent factors useful in the differential diagnosis of AOSD from adult HLH. In the differential diagnosis of both groups, the area under the curve obtained from the ROC curve of IL-18 with a cutoff value of 18,550 pg/mL was 0.91 (95% confidence interval 0.83–1.00; sensitivity 90.3%, specificity 93.5%), and the differential diagnosis ability of IL-18 was superior to that of other laboratory data. Conclusions IL-18 could be a useful biomarker for the differential diagnosis of AOSD and adult HLH.
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Affiliation(s)
- Toshihiko Shiga
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Yuji Nozaki
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Daisuke Tomita
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Kazuya Kishimoto
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Yasuaki Hirooka
- Department of Rheumatology, Kindai University Nara Hospital, Nara, Japan
| | - Koji Kinoshita
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Masanori Funauchi
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
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9
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Ponnatt TS, Lilley CM, Mirza KM. Hemophagocytic Lymphohistiocytosis. Arch Pathol Lab Med 2021; 146:507-519. [PMID: 34347856 DOI: 10.5858/arpa.2020-0802-ra] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder of immune regulation that can eventually result in end-organ damage and death. HLH is characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages that can lead to a cytokine storm. The diagnosis of HLH is often challenging due to the diverse clinical manifestations and the presence of several diagnostic mimics. The prognosis is generally poor, warranting rapid diagnosis and aggressive management. OBJECTIVE.— To provide a comprehensive review of the pathogenesis, clinical features, diagnosis, and management of HLH. DATA SOURCES.— Peer-reviewed literature. CONCLUSIONS.— HLH is a condition where a complete understanding of the pathogenesis, early diagnosis, and proper management has an important role in determining patient outcome. Genetic mutations causing impairment in the function of cytotoxic T lymphocytes and natural killer cells have been identified as the root cause of familial HLH; however, the specific pathogenesis of acquired HLH is unclear. The HLH-2004 protocol used in the diagnosis of HLH was originally developed for the pediatric population. The HLH-2004 protocol still forms the basis of the diagnosis of HLH in adults, although its use in adults has not been formally validated yet. Treatment of HLH is primarily based on the HLH-94 protocol, which involves suppressing the inflammatory response, but the treatment needs to be modified in adults depending on the underlying cause and comorbidities.
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Affiliation(s)
- Tanya Sajan Ponnatt
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Cullen M Lilley
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Kamran M Mirza
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
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10
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Tang S, Li S, Zheng S, Ding Y, Zhu D, Sun C, Hu Y, Qiao J, Fang H. Understanding of cytokines and targeted therapy in macrophage activation syndrome. Semin Arthritis Rheum 2020; 51:198-210. [PMID: 33385860 DOI: 10.1016/j.semarthrit.2020.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of systemic autoinflammatory/autoimmune diseases, generally systemic juvenile idiopathic arthritis and adult-onset Still's disease. It is characterized by an excessive proliferation of macrophages and T lymphocytes. Recent research revealed that cytokine storm with elevated pro-inflammatory cytokines, including IFN-γ, IL-18, and IL-6, may be central to the pathogenesis of MAS. Though the mainstream of MAS treatment remains corticosteroids and cyclosporine, targeted therapies with anti-cytokine biologics are reported to be promising for controlling systemic inflammation in MAS.
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Affiliation(s)
- Shunli Tang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Li
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Siting Zheng
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuwei Ding
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dingxian Zhu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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11
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Chi H, Wang Z, Meng J, Han P, Zhai L, Feng T, Teng J, Sun Y, Hu Q, Zhang H, Liu H, Cheng X, Ye J, Shi H, Wu X, Zhou Z, Jia J, Wan L, Liu T, Qiao X, Wang M, Wang F, Chen X, Yang C, Su Y. A Cohort Study of Liver Involvement in Patients With Adult-Onset Still's Disease: Prevalence, Characteristics and Impact on Prognosis. Front Med (Lausanne) 2020; 7:621005. [PMID: 33425966 PMCID: PMC7785871 DOI: 10.3389/fmed.2020.621005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/07/2020] [Indexed: 12/21/2022] Open
Abstract
Objective: Adult-onset Still's disease (AOSD) is a systemic disorder commonly accompanied by liver involvement. This study aims to illustrate the detailed information of liver abnormalities in patients with AOSD and evaluate the impact on the prognosis. Methods: A total number of 128 hospitalized patients, who met the Yamaguchi criteria of AOSD in the Department of Rheumatology and Immunology, Ruijin Hospital from July 2016 to August 2019 were consecutively enrolled and followed up. The demographic characteristics, clinical features, laboratory tests, treatments and prognosis were recorded. Correlations of liver function tests (LFTs) with disease activity and laboratory parameters were analyzed by the Spearman test. Risk factors of the refractory AOSD were evaluated by multivariate logistic regression analysis. Results: Liver involvement was presented in 104 (81.3%) patients with AOSD. We observed that 34 (32.7%) patients were with mild elevation, 32 (30.8%) patients were with moderate elevation, and 38 (36.5%) patients were with severe elevation. The majority of elevated ALT, AST and ALP decreased to normal within the range of 2 months, except for GGT. Furthermore, the LFTs were found significantly correlated with disease activity. Besides, we found patients with higher levels of LFTs tended to require more intensive treatments and suffered from poorer prognosis. Multivariate logistic regression analysis showed ALP ≥ 141 IU/L and GGT ≥ 132 IU/L are independent risk factors of refractory AOSD. Conclusion: Liver involvement is common in patients with AOSD, the levels of LFTs are associated with disease activity and related to the treatment strategies and prognosis.
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Affiliation(s)
- Huihui Chi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhihong Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfen Meng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Rheumatology and Immunology, The First People's Hospital of Yancheng, The Forth Affiliated Hospital of Nantong University, Yancheng, China
| | - Pingyang Han
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Rheumatology and Immunology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Limin Zhai
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tienan Feng
- Shanghai Tongren Hospital/Clinical Research Institute, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Clinical Research Promotion and Development Center, Shanghai Shenkang Hospital Development Center, Shanghai, China.,The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Zhang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyao Wu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuochao Zhou
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinchao Jia
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liyan Wan
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tingting Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Qiao
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengyan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xia Chen
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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12
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Abstract
The clinical and laboratory features of COVID-19 are reviewed with attention to the immunologic manifestations of the disease. Recent COVID-19 publications describe a variety of clinical presentations including an asymptomatic state, pneumonia, a hemophagocytic lymphohistiocytosis like syndrome, Multisystem Inflammatory Syndrome in Children (MIS-C) but, also called Pediatric Inflammatory Multisystem Syndrome-Toxic Shock (PIMS-TS), Kawasaki Disease, and myocarditis. A common theme amongst multiple reports suggests an overexuberant autoimmune component of the disease but a common pathophysiology to explain the variations in clinical presentation has been elusive. Review of the basic science of other viral induced autoimmune disorders may give clues as to why immunosuppressive and immunomodulating regimens now appear to have some efficacy in COVID-19. Review of the immunopathology also reveals other therapies that have yet to be explored. There is potential use of T cell depleting therapies and possibly anti-CD20 therapy for COVID-19 and clinical research using these medications is warranted.
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13
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Macrophage activation syndrome in adult dermatomyositis: a case-based review. Rheumatol Int 2020; 40:1151-1162. [PMID: 32356114 DOI: 10.1007/s00296-020-04590-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/18/2020] [Indexed: 12/22/2022]
Abstract
Macrophage activation syndrome (MAS) is a severe and life-threatening syndrome associated with autoimmune diseases, characterized by fever, hepatosplenomegaly, and pancytopenia. Dermatomyositis (DM) is one of the causes of MAS; however, its clinical characteristics in DM patients remain unclear. This study aimed to present a case of anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive DM complicated by MAS in a 29-year-old woman and to review the literatures including similar cases. Even though symptoms and cytopenia of our patient were refractory to combination therapy, including glucocorticoids, immunosuppressants, and plasma exchange, the administration of rituximab (RTX) resulted in rapid clinical improvement and glucocorticoid reduction. The literature review revealed 18 adult patients with DM associated MAS. Most patients developed MAS within 3 months from DM onset. A monotherapy of glucocorticoid was insufficient to control the disease, and the mortality of MAS in DM was higher than that of MAS in other rheumatic diseases, despite being treated by various means. RTX may be an effective treatment for patients with DM complicated by MAS who are refractory to conventional therapy. Anti-MDA5 antibody could influence the development of MAS; however, further investigations are needed to elucidate the association between myositis-specific antibody and MAS.
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14
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Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs 2020; 22:29-44. [PMID: 31732958 PMCID: PMC7334831 DOI: 10.1007/s40272-019-00367-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Macrophage activation syndrome (MAS), a form of secondary hemophagocytic lymphohistiocytosis, is a frequently fatal complication of a variety of pediatric inflammatory disorders. MAS has been most commonly associated with systemic juvenile idiopathic arthritis (sJIA), as approximately 10% of children with sJIA develop fulminant MAS, with another 30-40% exhibiting a more subclinical form of the disease. Children with other rheumatologic conditions such as systemic lupus erythematosus and Kawasaki disease are also at risk for MAS. Moreover, MAS also complicates various genetic autoinflammatory disorders such as gain of function mutations in the cytosolic inflammasome NLRC4, pediatric hematologic malignancies (e.g., T-cell lymphoma), and primary immunodeficiencies characterized by immune dysregulation. Disease-specific and broadly inclusive diagnostic criteria have been developed to facilitate the diagnosis of MAS. Recently, simple screening tools such as the serum ferritin to erythrocyte sedimentation rate ratio have been proposed. Early diagnosis and rapid initiation of immunosuppression are essential for the effective management of MAS. With a better understanding of the pathophysiology of MAS and the advent of novel therapeutics, a broad immunosuppressive approach to treatment is giving way to targeted anti-cytokine therapies. These treatments include agents that block interleukin-1 (IL-1), IL-6, IL-18, interferon-γ, as well as inhibitors of downstream targets of cytokine signaling (e.g., Janus kinases). Increased early recognition of MAS among pediatric inflammatory disorders combined with the use of effective and less toxic cytokine-targeted therapies should lower the mortality of this frequently fatal disorder.
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Affiliation(s)
- Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, 1 Blackfan Circle, 10th Floor Karp Family Research Building, Boston, MA 02115, USA
| | - Randy Q. Cron
- Division of Pediatric Rheumatology, Children’s of Alabama, 1600 7th Ave. S., CPPN, suite G10, Birmingham, AL 35233-1711, USA
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15
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A Review on Macrophage Activation Syndrome. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2019. [DOI: 10.22207/jpam.13.1.19] [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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16
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Abstract
Macrophage activation syndrome (MAS) is a life-threatening condition, and it is a subset of hemophagocytic lymphohistiocytosis (HLH). The clinical features include a persistent high-grade fever, hepatosplenomegaly, lymphadenopathy, hemorrhagic manifestations, and a sepsis-like condition. From the clinical features, it is usually difficult to differentiate between a true sepsis, disease flare-ups, or MAS. Although the laboratory abnormalities are similar to those of a disseminated intravascular coagulation, which shows pancytopenia, coagulopathy, hypofibrinogenemia, and an elevated d-dimer test, it can also be a late stage of MAS. Currently, MAS is still underrecognized and usually results in delayed in diagnosis, which leads to high morbidity and mortality. This literature review was conducted in the context of the clinical manifestations and the laboratory abnormalities in MAS, which might provide some clues for an early diagnosis. The best ways for an early recognition and a satisfactory diagnosis were based on the relative changes in the overall parameters from the baseline, together with a thorough and continuous physical examination for these kinds of patients. At present, diagnostic criteria have been proposed for HLH, MAS-associated systemic juvenile idiopathic arthritis, and an MAS-associated systemic lupus erythematosus. Therefore, selecting the proper diagnostic criteria for use is essential because not all of the criteria are suitable for every autoimmune disease.
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Affiliation(s)
- Butsabong Lerkvaleekul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,
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17
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Mehta B, Kasturi S, Teruya-Feldstein J, Horwitz S, Bass AR, Erkan D. Adult-Onset Still's Disease and Macrophage-Activating Syndrome Progressing to Lymphoma: A Clinical Pathology Conference Held by the Division of Rheumatology at Hospital for Special Surgery. HSS J 2018; 14:214-221. [PMID: 29983666 PMCID: PMC6031528 DOI: 10.1007/s11420-018-9606-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Bella Mehta
- 0000 0001 2285 8823grid.239915.5Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,000000041936877Xgrid.5386.8Weill Cornell Medicine, New York, NY USA
| | - Shanthini Kasturi
- 0000 0000 8934 4045grid.67033.31Tufts Medical Center, Boston, MA USA
| | - Julie Teruya-Feldstein
- 0000 0000 9963 6690grid.425214.4Icahn School of Medicine, Mount Sinai Health System, New York, NY USA
| | - Steven Horwitz
- 0000 0001 2171 9952grid.51462.34Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Anne R. Bass
- 0000 0001 2285 8823grid.239915.5Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,000000041936877Xgrid.5386.8Weill Cornell Medicine, New York, NY USA
| | - Doruk Erkan
- 0000 0001 2285 8823grid.239915.5Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,000000041936877Xgrid.5386.8Weill Cornell Medicine, New York, NY USA
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18
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Fauteux-Daniel S, Viel S, Besson L, Zhang J, Marotel M, Mathieu AL, Pescarmona R, Charrier E, Henry T, Belot A, Walzer T. Deletion of Inflammasome Components Is Not Sufficient To Prevent Fatal Inflammation in Models of Familial Hemophagocytic Lymphohistiocytosis. THE JOURNAL OF IMMUNOLOGY 2018; 200:3769-3776. [PMID: 29695416 DOI: 10.4049/jimmunol.1701628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/27/2018] [Indexed: 11/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe inflammatory condition that occurs in patients with genetic defects of cytotoxicity (familial HLH [FHL]) or secondary to other immunological disorders such as juvenile idiopathic arthritis. HLH is characterized by elevated levels of serum IL-18 and other cytokines. Moreover, a novel clinical entity has been recently identified in which constitutive NLRC4 inflammasome activation leads to severe HLH. Altogether, these clinical observations suggest that inflammasome activation is a central event in the development of all HLH forms and that inflammasome blockade could alleviate inflammation in FHL patients. To formally address this question, we invalidated genes encoding for Caspase-1 or the inflammasome adapter ASC in perforin-deficient mice that were subsequently infected with lymphocytic or mouse choriomeningitis virus as models of FHL. These deletions nearly abrogated IL-18 production occurring during HLH in all models. However, they did not reduce serum IFN-γ levels at the peak of the inflammatory reaction nor did they modulate inflammatory parameters at mid and late stages or fatal outcome. These data show that inflammasome blockade is not sufficient to prevent cytokine storm and lethality in mouse models of FHL and suggest that different pathophysiological mechanisms underlie HLH in genetic defects of cytotoxicity and genetic forms of inflammasome activation.
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Affiliation(s)
- Sébastien Fauteux-Daniel
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Sébastien Viel
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France.,Service de Biologie, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, Lyon 69310, France; and
| | - Laurie Besson
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Jiang Zhang
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Marie Marotel
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Anne-Laure Mathieu
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Rémi Pescarmona
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France.,Service de Biologie, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, Lyon 69310, France; and
| | - Emily Charrier
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Thomas Henry
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
| | - Alexandre Belot
- Centre International de Recherche en Infectiologie, Lyon 69007, France.,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France.,Service de Néphrologie-Rhumatologie-Dermatologie Pédiatriques, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, Lyon 69677, France
| | - Thierry Walzer
- Centre International de Recherche en Infectiologie, Lyon 69007, France; .,Inserm, U1111, Lyon 69007, France.,École Normale Supérieure de Lyon, Lyon 69007, France.,Université Lyon 1, Lyon 69100, France.,CNRS, UMR5308, Centre International de Recherche en Infectiologie, Lyon 69007, France
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19
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Kawasumi H, Katsumata Y, Nishino A, Hirahara S, Kawaguchi Y, Kuwana M, Yamanaka H. Association of Serum Soluble CD163 with Polymyositis and Dermatomyositis, Especially in Anti-MDA5 Antibody–positive Cases. J Rheumatol 2018; 45:947-955. [DOI: 10.3899/jrheum.170997] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2018] [Indexed: 01/24/2023]
Abstract
Objective.We elucidated the association of serum soluble CD163 (sCD163) with rapidly progressive interstitial lung disease (RP-ILD), autoantibody profiles, and serum ferritin in patients with polymyositis (PM), classic dermatomyositis (DM), and clinical amyopathic dermatomyositis (CADM).Methods.Serum sCD163 levels were retrospectively measured by ELISA in patients with PM, classic DM, and CADM, as well as in healthy controls (HC). Repeat sera samples were obtained posttreatment from available patients. The associations between serum sCD163 levels and clinical information were analyzed.Results.Serum sCD163 levels in patients with PM/classic DM/CADM were significantly higher than those in HC (n = 72, 56, 34, and 68, respectively; p < 0.001 for all comparisons). No significant difference was observed between serum sCD163 levels in patients with and without ILD (p = 0.16) or between those with RP-ILD and chronic ILD (p = 0.21). Serum sCD163 levels were significantly higher in patients with anti-MDA5 antibodies (n = 27) than in those without (p = 0.001). Serum sCD163 levels were weakly correlated with serum ferritin levels in the patients with PM, classic DM, and CADM (r = 0.21). Serum sCD163 levels decreased significantly following treatment in all patient groups (p = 0.003).Conclusion.The present results suggest an association of serum sCD163 with PM, classic DM, and CADM, especially in anti-MDA5 antibody–positive cases. However, serum sCD163 levels were not specifically associated with ILD or RP-ILD.
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20
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Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
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Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
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21
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Nusshag C, Morath C, Zeier M, Weigand MA, Merle U, Brenner T. Hemophagocytic lymphohistiocytosis in an adult kidney transplant recipient successfully treated by plasmapheresis: A case report and review of the literature. Medicine (Baltimore) 2017; 96:e9283. [PMID: 29390386 PMCID: PMC5815798 DOI: 10.1097/md.0000000000009283] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease entity primarily described in children, but not less relevant in adults. It is characterized by a misdirected activation of the immune system, resulting in an uncontrolled cytokine release from macrophages and cytotoxic T-cells (CTLs). Primary HLH relies on a genetic predisposition, whereas secondary HLH develops in the context of infections, malignancies or autoimmune diseases. However, the awareness and therapeutic knowledge for HLH in adulthood is limited. Most therapy protocols are almost exclusively validated in pediatric cohorts and for primary HLH. Their transferability to adult individuals with mostly secondary HLH is doubtful. Especially the high liver and bone marrow toxicity of applied etoposide-based protocols is discussed controversially and connected to overwhelming infections and death. PATIENT CONCERN A 51-year old, male, kidney transplant recipient was admitted to our center suffering from diarrhea, fever, nausea, hyponatremia, kidney graft failure, disorientation, progressive hemodynamic instability, and multiorgan failure. DIAGNOSES Clinical and laboratory findings resembled those of a septic shock. Ferritin and soluble interleukin-2 receptor (sCD25) levels were disproportionally elevated. Only a mild hepatosplenomegaly was diagnosed in a CT scan. A T2-weighted, fluid-attenuated inversion recovery MRI showed marked, bilateral and periventricular white matter hyperintensities. The cerebrospinal fluid (CSF) analysis showed a moderately elevated protein content and cell count. There was no evidence of any bacterial, viral, or parasitic infection. The diagnosis of HLH was made. INTERVENTIONS & OUTCOMES The patient was successfully treated by a combined approach consisting of plasma exchange (PE), corticosteroids, anakinra, and cyclosporine (CsA). LESSONS HLH is an important differential diagnosis in critically ill patients. Its unspecific clinical picture complicates an early diagnosis and may be misclassified as sepsis. A combination of plasma exchange (PE), corticosteroids, anakinra, and cyclosporine (CsA) may be a promising and less toxic approach for HLH therapy in adults.
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Affiliation(s)
| | | | | | | | - Uta Merle
- Departement of Gastroenterology, Heidelberg University Hospital, Germany
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22
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Kernan KF, Carcillo JA. Hyperferritinemia and inflammation. Int Immunol 2017; 29:401-409. [PMID: 28541437 PMCID: PMC5890889 DOI: 10.1093/intimm/dxx031] [Citation(s) in RCA: 328] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/23/2017] [Indexed: 12/18/2022] Open
Abstract
Understanding of ferritin biology has traditionally centered on its role in iron storage and homeostasis, with low ferritin levels indicative of deficiency and high levels indicative of primary or secondary hemochromatosis. However, further work has shown that iron, redox biology and inflammation are inexorably linked. During infection, increased ferritin levels represent an important host defense mechanism that deprives bacterial growth of iron and protects immune cell function. It may also be protective, limiting the production of free radicals and mediating immunomodulation. Additionally, hyperferritinemia is a key acute-phase reactants, used by clinicians as an indication for therapeutic intervention, aimed at controlling inflammation in high-risk patients. One school of thought maintains that hyperferritinemia is an 'innocent bystander' biomarker of uncontrolled inflammation that can be used to gauge effectiveness of intervention. Other schools of thought maintain that ferritin induction could be a protective negative regulatory loop. Others maintain that ferritin is a key mediator of immune dysregulation, especially in extreme hyperferritinemia, via direct immune-suppressive and pro-inflammatory effects. There is a clear need for further investigation of the role of ferritin in uncontrolled inflammatory conditions both as a biomarker and mediator of disease because its occurrence identifies patients with high mortality risk and its resolution predicts their improved survival.
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Affiliation(s)
- Kate F Kernan
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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23
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Clinical utility of soluble interleukin-2 receptor in hemophagocytic syndromes: a systematic scoping review. Ann Hematol 2017; 96:1241-1251. [PMID: 28497365 DOI: 10.1007/s00277-017-2993-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/11/2017] [Indexed: 12/22/2022]
Abstract
The serum-soluble interleukin-2 receptor (sIL-2r) level is considered an important diagnostic test and disease marker in hemophagocytic syndromes/hemophagocytic lymphohistiocytosis (HPS/HLH). However, this cytokine receptor is rarely measured in clinical practice and has been excluded from recent diagnostic/classification criteria such as the HScore and macrophage activation syndrome (MAS) 16. We performed a systematic scoping review of 64 articles (1975-2016) examining the clinical utility of sIL-2r in HPS/HLH. Twenty-two articles describe sIL-2r as a sensitive diagnostic marker for HLH, but only three distinct datasets actually address sensitivity. The original HLH-2004 Guidelines reported sensitivity of 93% and specificity of 100% for sIL-2r ≥ 2400, based on a pediatric dataset (n = 152) which is published for the first time in this review. Two pediatric studies reported sensitivity of 89% for sIL-2r ≥ 2400 in diagnosis of MAS complicating juvenile idiopathic arthritis (JIA) (n = 27) and 88% for secondary HLH in acute liver failure (n = 9). Twenty articles described sIL-2r as a dynamic marker of disease activity that falls with response to treatment, and 15 described high initial sIL-2r levels >10,000 U/mL as a poor prognostic marker. The ability of sIL-2r to distinguish between subtypes of HPS/HLH was inconsistent. This review confirms the importance of soluble IL-2r as a diagnostic and disease marker in HPS/HLH, but also reveals the need for more primary data about its performance characteristics, particularly in adults. More emphasis should be made in including this simple, inexpensive test in clinical practice and studies of HPS/HLH.
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Carreras-Badosa G, Prats-Puig A, Diaz-Roldan F, Platero-Gutierrez E, Osiniri I, Riera-Perez E, de Zegher F, Ibañez L, Bassols J, López-Bermejo A. The macrophage activation product sCD163 is associated with a less favourable metabolic profile in prepubertal children. Pediatr Obes 2016; 11:543-550. [PMID: 26843034 DOI: 10.1111/ijpo.12104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Macrophages are known to be involved in low-grade inflammatory processes such as obesity. soluble cluster of differentiation 163 (sCD163) is shed from the cell surface as specific macrophage activation marker. In prepubertal children, we studied if circulating sCD163 is associated with metabolic and cardiovascular risk markers. METHODS A population of 236 school-aged Caucasian children (111 girls and 125 boys) aged 8 ± 1 year [81 normal weight (body mass index [BMI]-SDS < 1); 74 overweight (1 ≤ BMI-standard deviation score [SDS] < 2) and 81 with obesity (BMI-SDS ≥ 2)] were studied. BMI, waist circumference, fat mass and visceral fat were measured. Fasting serum sCD163, homeostatic model assessment of insulin resistance, high sensitivity C-reactive protein, gamma-glutamyl transpeptidase and lipids were quantified. RESULTS Circulating sCD163 concentrations were higher in children with obesity (p < 0.0001). Associations were observed between circulating sCD163 and a less favourable metabolic profile as judged by higher waist circumference, fat mass, visceral fat, epicardial fat, homeostatic model assessment of insulin resistance, high sensitivity C-reactive protein, gamma-glutamyl transpeptidase and triglycerides (all between r = 0.173 and r = 0.363; p < 0.05 to p < 0.0001) and lower high-density lipoprotein-cholesterol (r = -0.285, p < 0.0001). In multiple regression analyses, circulating sCD163 was independently associated with HOMA-IR (β = 0.162, p = 0.016; model R2 = 0.179) and high density lipoprotein-cholesterol/triglycerides ratio (β = -0.167, p = 0.012; model R2 = 0.209). CONCLUSIONS Childhood obesity may increase the risk of developing metabolic diseases later in life through chronic macrophage activation having deleterious effects on metabolism.
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Affiliation(s)
| | - A Prats-Puig
- Girona Institute for Biomedical Research, Girona, Spain.,EUSES University School, Girona, Spain
| | - F Diaz-Roldan
- Girona Institute for Biomedical Research, Girona, Spain.,Dr Josep Trueta Hospital, Girona, Spain
| | - E Platero-Gutierrez
- Girona Institute for Biomedical Research, Girona, Spain.,Dr Josep Trueta Hospital, Girona, Spain
| | - I Osiniri
- Salut Empordà Foundation, Figueres, Spain
| | | | | | - L Ibañez
- Sant Joan de Déu Children's Hospital, Barcelona, Spain.,CIBERDEM, Madrid, Spain
| | - J Bassols
- Girona Institute for Biomedical Research, Girona, Spain
| | - A López-Bermejo
- Girona Institute for Biomedical Research, Girona, Spain.,Dr Josep Trueta Hospital, Girona, Spain
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25
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Grom AA, Ilowite NT, Pascual V, Brunner HI, Martini A, Lovell D, Ruperto N, Leon K, Lheritier K, Abrams K. Rate and Clinical Presentation of Macrophage Activation Syndrome in Patients With Systemic Juvenile Idiopathic Arthritis Treated With Canakinumab. Arthritis Rheumatol 2016; 68:218-28. [PMID: 26314396 DOI: 10.1002/art.39407] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/25/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In pivotal trials, canakinumab has been shown to be effective in the treatment of systemic juvenile idiopathic arthritis (JIA), but reported adverse events have included macrophage activation syndrome (MAS). This study was undertaken to assess the impact of canakinumab on MAS incidence. METHODS An independent MAS Adjudication Committee (MASAC), consisting of 3 of the authors, was convened, and a search of databases from clinical studies of canakinumab treatment in systemic JIA was performed using MASAC-specified adverse event terms to identify potential MAS events. These were then adjudicated as "probable MAS," "possible MAS," or "MAS unlikely," using criteria developed by the MASAC. MAS rates were expressed as numbers of cases per 100 patient-years. RESULTS Of 72 potential MAS cases identified, 21 events (19 with canakinumab treatment; 2 with placebo treatment) in 19 patients were adjudicated as being probable MAS and 10 events in 9 patients as being possible MAS. Systemic JIA was well controlled in the majority of canakinumab-treated patients at the time of MAS. The time period between initiation of canakinumab treatment and onset of MAS ranged from 3 to 1,358 days (median 292 days). When the rates of probable MAS events were compared between canakinumab-treated patients (2.8 per 100 patient-years) and placebo-treated patients (7.7 per 100 patient-years), the difference was not significant (-4.9 [95% confidence interval -15.6, 5.9]). There were 3 deaths due to MAS-related complications (2 in patients receiving canakinumab; 1 in a patient receiving placebo); full recovery was reported in all other patients. Infections were the most common trigger of MAS, and the clinical features of MAS were not modified by canakinumab. CONCLUSION Canakinumab does not have a significant effect on MAS risk or its clinical features in patients with systemic JIA. Infections are the most common trigger, and MAS occurs even in patients whose systemic JIA is well controlled with this treatment.
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Affiliation(s)
- Alexei A Grom
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Alberto Martini
- Università di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Karolynn Leon
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Ken Abrams
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of rheumatic diseases such as systemic juvenile idiopathic arthritis (sJIA) and systemic lupus erythematosus. It is often considered a type of secondary hemophagocytic lymphohistiocytosis (HLH) and results from over-activation of T lymphocytes and macrophages leading to a "cytokine storm". Characteristic features are persistent fever, lymphadenopathy, hepatosplenomegaly, cytopenias (anemia, leucopenia, thrombocytopenia), raised C-reactive protein, falling erythrocyte sedimentation rate, hypofibrinogenemia, transaminitis, hypertriglyceridemia and extreme hyperferritinemia often associated with multi-organ impairment. Key to its management is early recognition of MAS which may be difficult due to similarity to systemic sepsis or flares of the underlying rheumatic disease. To aid with this process, criteria for the diagnosis of MAS in patients with sJIA derived by international consensus have been published. Although bone marrow biopsy showing hemophagocytosis is strongly supportive it is not essential for diagnosis. Together with appropriate supportive care, first-line treatment is high-dose intravenous corticosteroids with cyclosporin or intravenous immunoglobulin (IVIg) added if there is not initial response. Although etoposide is used by hematologists in treatment of HLH, there are concerns regarding organ toxicity and bone marrow suppression which weigh against its use in initial management of MAS. With increasing understanding of the pathogenesis of MAS, use of drugs targeting specific cytokines has been reported in case series. The relatively rapid effectiveness of anakinra, a recombinant IL-1 receptor antagonist, has been documented. Further studies of this and other biologic agents are required to identify the most effective and safest treatment option for refractory MAS.
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27
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Ozturk K, Ekinci Z. Successful treatment of macrophage activation syndrome due to systemic onset juvenile idiopathic arthritis with antithymocyte globulin. Rheumatol Int 2015. [DOI: 10.1007/s00296-015-3321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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28
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Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of rheumatic disorders that occurs most commonly in systemic juvenile idiopathic arthritis. In recent years, there have been several advances in the understanding of the pathophysiology of MAS. Furthermore, new classification criteria have been developed. Although the place of cytokine blockers in the management of MAS is still unclear, interleukin-1 inhibitors represent a promising adjunctive therapy, particularly in refractory cases.
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Affiliation(s)
- Angelo Ravelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Head, Center of Rheumatology, University of Genoa and G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy.
| | - Sergio Davì
- Second Pediatric Division and Rheumatology, G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Francesca Minoia
- Second Pediatric Division and Rheumatology, G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Alberto Martini
- Department of Pediatrics and Second Pediatric Division and Rheumatology, University of Genoa and G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Randy Q Cron
- Director, Division of Pediatric Rheumatology, Children's Hospital of Alabama and University of Alabama at Birmingham, Children's Park Place, Ste. 210 1601 4th Avenue South Birmingham, AL 35233, USA
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Macrophage Activation Syndrome as Onset of Systemic Lupus Erythematosus: A Case Report and a Review of the Literature. Case Rep Med 2015; 2015:294041. [PMID: 26064125 PMCID: PMC4439481 DOI: 10.1155/2015/294041] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/23/2015] [Indexed: 11/23/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal condition. It belongs to the hemophagocytic lymphohistiocytosis group of diseases. In adults, MAS is rarely associated with systemic lupus erythematosus, but it also arises as complication of several systemic autoimmune disorders, like ankylosing spondylitis, rheumatoid arthritis, and adult-onset Still's disease. Several treatment options for MAS have been reported in the literature, including a therapeutic regimen of etoposide, dexamethasone, and cyclosporine. Here we report a case of 42-year-old woman in whom MAS occurred as onset of systemic lupus erythematosus.
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30
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Schulert GS, Grom AA. Pathogenesis of macrophage activation syndrome and potential for cytokine- directed therapies. Annu Rev Med 2014; 66:145-59. [PMID: 25386930 DOI: 10.1146/annurev-med-061813-012806] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Macrophage activation syndrome (MAS) is an acute episode of overwhelming inflammation characterized by activation and expansion of T lymphocytes and hemophagocytic macrophages. In rheumatology, it occurs most frequently in patients with systemic juvenile idiopathic arthritis (SJIA) and systemic lupus erythematosus. The main clinical manifestations include cytopenias, liver dysfunction, coagulopathy resembling disseminated intravascular coagulation, and extreme hyperferritinemia. Clinically and pathologically, MAS bears strong similarity to hemophagocytic lymphohistiocytosis (HLH), and some authors prefer the term secondary HLH to describe it. Central to its pathogenesis is a cytokine storm, with markedly increased levels of numerous proinflammatory cytokines including IL-1, IL-6, IL-18, TNFα, and IFNγ. Although there is evidence that IFNγ may play a central role in the pathogenesis of MAS, the role of other cytokines is still not clear. There are several reports of SJIA-associated MAS dramatically benefiting from anakinra, a recombinant IL-1 receptor antagonist, but the utility of other biologics in MAS is not clear. The mainstay of treatment remains corticosteroids; other medications, including cyclosporine, are used in patients who fail to respond.
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Affiliation(s)
- Grant S Schulert
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, Cincinnati, Ohio 45229; ,
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31
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Abstract
Macrophage activation syndrome (MAS) is an episode of overwhelming inflammation that occurs most commonly in children with systemic juvenile idiopathic arthritis (SJIA). It is characterized by expansion and activation of T lymphocytes and hemophagocytic macrophages and bears great similarity to hemophagocytic lymphohistiocytosis (HLH). This disorder has substantial morbidity and mortality, and there is frequently a delay in recognition and initiation of treatment. Here, we will review what is known about the pathogenesis of MAS and, in particular, its similarities to HLH. The development of MAS is characterized by a cytokine storm, with the elaboration of numerous pro-inflammatory cytokines. We will examine the evidence for various cytokines in the initiation and pathogenesis of MAS and discuss how new biologic therapies may alter the risk of MAS. Finally, we will review current treatment options for MAS and examine how cytokine-directed therapy could serve as novel treatment modalities.
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Affiliation(s)
- Grant S Schulert
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Alexei A Grom
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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32
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Advances in the pathogenesis and treatment of systemic juvenile idiopathic arthritis. Pediatr Res 2014; 75:176-83. [PMID: 24213625 DOI: 10.1038/pr.2013.187] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/11/2013] [Indexed: 11/08/2022]
Abstract
Systemic juvenile idiopathic arthritis (s-JIA) is clinically distinct from other types of JIA. It is typified by extraarticular features such as quotidian fevers, rash, splenomegaly, lymphadenopathy, laboratory abnormalities (including leukocytosis, thrombocytosis, anemia, hyperferritinemia, and elevated inflammatory markers), and a close association with the macrophage activation syndrome. Recent investigations have highlighted dysregulation of the innate immune system as the critical pathogenic driver of s-JIA. Key innate immune mediators of s-JIA are the macrophage-derived cytokines interleukin-1 (IL-1) and IL-6. Increased understanding of the roles of IL-1 and IL-6 in the pathogenesis of s-JIA has led to major changes in therapeutic options. Until recently, the most commonly used medications included corticosteroids, methotrexate, and tumor necrosis factor (TNF) inhibitors, which are incompletely effective in most cases. Newer biologic agents targeting IL-1 and IL-6 have proven very effective in treating s-JIA and in minimizing corticosteroid exposure. Here we review recent advances in the understanding of the pathogenesis of s-JIA and the recent clinical trials that have revolutionized the care of children with s-JIA.
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Kaieda S, Yoshida N, Yamashita F, Okamoto M, Ida H, Hoshino T, Fukuda T. Successful treatment of macrophage activation syndrome in a patient with dermatomyositis by combination with immunosuppressive therapy and plasmapheresis. Mod Rheumatol 2013; 25:962-6. [PMID: 24252010 DOI: 10.3109/14397595.2013.844402] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Macrophage activation syndrome (MAS), also known as secondary hemophagocytic lymphohistiocytosis, is mediated by cytokine overproduction from excessive activation of T lymphocytes and macrophages. We present a dermatomyositis patient with MAS, caused by hypercytokinemia. The combination of tacrolimus and plasma exchange therapy was effective in this case for treating MAS. This combination therapy is especially useful for MAS refractory to steroids.
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Affiliation(s)
- Shinjiro Kaieda
- a Department of Medicine , Division of Respirology, Neurology and Rheumatology, Kurume University School of Medicine , Kurume , Japan
| | - Naomi Yoshida
- a Department of Medicine , Division of Respirology, Neurology and Rheumatology, Kurume University School of Medicine , Kurume , Japan
| | - Fumiya Yamashita
- a Department of Medicine , Division of Respirology, Neurology and Rheumatology, Kurume University School of Medicine , Kurume , Japan
| | - Masaki Okamoto
- a Department of Medicine , Division of Respirology, Neurology and Rheumatology, Kurume University School of Medicine , Kurume , Japan
| | - Hiroaki Ida
- a Department of Medicine , Division of Respirology, Neurology and Rheumatology, Kurume University School of Medicine , Kurume , Japan
| | - Tomoaki Hoshino
- a Department of Medicine , Division of Respirology, Neurology and Rheumatology, Kurume University School of Medicine , Kurume , Japan
| | - Takaaki Fukuda
- b Center for Rheumatic Diseases, Kurume University Medical Center , Kurume , Japan
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34
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Abstract
SIGNIFICANCE The hemoglobin (Hb) scavenger receptor, CD163, is a macrophage-specific protein and the upregulated expression of this receptor is one of the major changes in the macrophage switch to alternative activated phenotypes in inflammation. Accordingly, a high CD163 expression in macrophages is a characteristic of tissues responding to inflammation. The scavenging of the oxidative and proinflammatory Hb leading to stimulation of the heme-oxygenase-1 and production of anti-inflammatory heme metabolites indicates that CD163 thereby indirectly contributes to the anti-inflammatory response. RECENT ADVANCES In addition to this biological role in inflammation, CD163 is a potential inflammation biomarker and a therapeutic target. The biomarker form of CD163 is the soluble plasma CD163 that arises from the increased shedding of CD163 mediated by the tumor necrosis factor-α (TNF-α) cleaving enzyme. This explains that a steadily increasing literature documents that the plasma level of soluble CD163 is increased in a large spectrum of acute and chronic inflammatory disorders. The nonshed membrane form of CD163 in macrophages constitutes a target for drugs to be directed to macrophages in inflammation. This approach has been used in an animal inflammation model to highly increase the apparent therapeutic index of anti-inflammatory glucocorticoid drug that was coupled to an anti-CD163 antibody. Furthermore, other recent animal data, which indirectly involve CD163 in macrophages, demonstrate that injections of haptoglobin attenuate Hb-induced damages after blood transfusion. CRITICAL ISSUES AND FUTURE DIRECTIONS The diagnostic and therapeutic properties of CD163 await further clinical studies and regulatory approval before implementation in the clinic.
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MESH Headings
- Animals
- Antigens, CD/chemistry
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Differentiation, Myelomonocytic/chemistry
- Antigens, Differentiation, Myelomonocytic/genetics
- Antigens, Differentiation, Myelomonocytic/metabolism
- Biomarkers/metabolism
- Gene Expression Regulation
- Haptoglobins/metabolism
- Hemoglobins/metabolism
- Humans
- Inflammation/diagnosis
- Inflammation/genetics
- Inflammation/metabolism
- Inflammation/therapy
- Macrophages/drug effects
- Macrophages/metabolism
- Receptors, Cell Surface/chemistry
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/metabolism
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Affiliation(s)
- Anders Etzerodt
- Department of Biomedicine, University of Aarhus, Aarhus C, Denmark
| | - Søren K. Moestrup
- Department of Biomedicine, University of Aarhus, Aarhus C, Denmark
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus C, Denmark
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35
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Lattanzi B, Davi S, Rosina S, Solari N, Lanni S, Bracciolini G, Martini A, Ravelli A. Macrophage activation syndrome. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60026-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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36
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Ravelli A, Grom AA, Behrens EM, Cron RQ. Macrophage activation syndrome as part of systemic juvenile idiopathic arthritis: diagnosis, genetics, pathophysiology and treatment. Genes Immun 2012; 13:289-98. [PMID: 22418018 DOI: 10.1038/gene.2012.3] [Citation(s) in RCA: 265] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Macrophage activation syndrome (MAS) is a severe, frequently fatal complication of systemic juvenile idiopathic arthritis (sJIA) with features of hemophagocytosis leading to coagulopathy, pancytopenia, and liver and central nervous system dysfunction. MAS is overt in 10% of children with sJIA but occurs subclinically in another 30-40%. It is difficult to distinguish sJIA disease flare from MAS. Development of criteria for establishing MAS as part of sJIA are under way and will hopefully prove sensitive and specific. Mutations in cytolytic pathway genes are increasingly being recognized in children who develop MAS as part of sJIA. Identification of these mutations may someday assist in MAS diagnosis. Defects in cytolytic genes have provided murine models of MAS to study pathophysiology and treatment. Recently, the first mouse model of MAS not requiring infection but rather dependent on repeated stimulation through Toll-like receptors was reported. This provides a model of MAS that may more accurately reflect MAS pathology in the setting of autoinflammation or autoimmunity. This model confirms the importance of a balance between pro- and anti-inflammatory cytokines. There has been remarkable progress in the use of anti-pro-inflammatory cytokine therapy, particularly against interleukin-1, in the treatment of secondary forms of MAS, such as in sJIA.
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Affiliation(s)
- A Ravelli
- Department of Pediatrics, Università degli Studi di Genova, Genova, Italy
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37
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Møller HJ. Soluble CD163. Scandinavian Journal of Clinical and Laboratory Investigation 2011; 72:1-13. [DOI: 10.3109/00365513.2011.626868] [Citation(s) in RCA: 258] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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38
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Tang Y, Liao C, Xu X, Song H, Shi S, Yang S, Zhao F, Xu W, Chen X, Mao J, Zhang L, Pan B. Evaluation of Th1/Th2 cytokines as a rapid diagnostic tool for severe infection in paediatric haematology/oncology patients by the use of cytometric bead array technology. Clin Microbiol Infect 2011; 17:1666-73. [DOI: 10.1111/j.1469-0691.2011.03490.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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39
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Raschke RA, Garcia-Orr R. Hemophagocytic lymphohistiocytosis: a potentially underrecognized association with systemic inflammatory response syndrome, severe sepsis, and septic shock in adults. Chest 2011; 140:933-938. [PMID: 21737492 DOI: 10.1378/chest.11-0619] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) was originally described as a genetic disorder of immune regulation, presenting in neonates with protracted fever, hepatosplenomegaly, and cytopenia. A secondary form of HLH, triggered by serious infections, was subsequently described in adults. METHODS We report three adult patients who presented with systemic inflammatory response syndrome and features consistent with severe sepsis and septic shock, who subsequently received a diagnosis of secondary HLH. We reviewed the relationship between infection-triggered HLH and septic shock from the perspective of the adult intensivist. RESULTS The hyperinflammatory pathophysiologic characteristics of HLH and septic shock are closely intertwined. Clinical and laboratory features of HLH and septic shock overlap in some patients, making the syndromes difficult to distinguish. In our experience and review, progressive pancytopenia was the feature most likely to suggest secondary HLH in the adult patient with presumed (or definite) septic shock. Use of other HLH-2004 diagnostic criteria is hindered by the poor operating characteristics of these tests in critically ill adults. Bone marrow aspiration is the most useful diagnostic test, but may yield an initial false-negative result. CONCLUSION The HLH-2004 treatment protocol is not of proven benefit in critically ill adults, but observational data suggest that aggressive immunosuppressive therapy should not be delayed. Further study of HLH in the critical care setting might provide important insights into the pathogenesis and clinical treatment of sepsis.
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Affiliation(s)
- Robert A Raschke
- Department of Medicine, Section of Critical Care Medicine, Banner Good Samaritan Medical Center, Phoenix, AZ.
| | - Roxanne Garcia-Orr
- Department of Pulmonary/Critical Care, Banner Good Samaritan Medical Center/Carl T. Hayden Veterans Affairs Medical Center, Phoenix, AZ
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40
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George MR, Herman JH, Holdbrook T, Cui C, Vardhana HG, Behling EM. Platelet refractoriness in acquired hemophagocytic syndrome. Transfusion 2011; 51:2319-26. [PMID: 21599673 DOI: 10.1111/j.1537-2995.2011.03182.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acquired hemophagocytic syndrome (AHPS) is a severe inflammatory disorder often caused by Epstein-Barr virus (EBV). Proliferation of activated macrophages produces uncontrolled cytokine production. Thrombocytopenia is common in AHPS, previously attributed to inadequate or ineffective marrow platelet (PLT) production. PLT transfusion response is not well reported. Two patients with fatal AHPS developed unexplained PLT transfusion refractoriness before definitive diagnosis. CASE REPORTS PLT refractoriness was noted during the care of two patients. The refractoriness was determined to be nonimmune and both demonstrated various clinical signs and laboratory findings consistent with AHPS. The first patient's AHPS was attributable to EBV infection. In the other patient, no underlying cause could be found. Both patients had an aggressive clinical course and succumbed to this relatively rare syndrome. The PLT refractoriness was evident before the AHPS diagnosis was made. DISCUSSION AHPS is not generally a consideration in the evaluation of nonimmune PLT refractoriness. However, these illustrative cases make an argument for its consideration in the differential diagnosis of PLT refractoriness in severely ill patients. Once present, it is unclear if the refractoriness can be reversed by AHPS-targeted therapy.
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Affiliation(s)
- Melissa R George
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 17033, USA.
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41
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Abstract
PURPOSE OF REVIEW Macrophage activation syndrome (MAS), a major cause of morbidity and mortality in pediatric rheumatology, is most strongly associated with systemic juvenile idiopathic arthritis (SJIA). There are no validated diagnostic criteria and early diagnosis is difficult. This review summarizes the progress in understanding of MAS pathophysiology that may help define specific diagnostic biomarkers. RECENT FINDINGS MAS is similar to the autosomal recessive disorders collectively known as familial hemophagocytic lymphohistiocytosis (FHLH), all associated with various genetic defects affecting the cytolytic pathway. Cytolytic function is profoundly depressed in SJIA with MAS as well. This immunologic abnormality distinguishes SJIA from other rheumatic diseases and is caused by both genetic and acquired factors. Phenotypic characterization of hemophagocytic macrophages has been another focus of research. These macrophages express CD163, a scavenger receptor that binds hemoglobin-haptoglobin complexes, and initiate pathways important for adaptation to oxidative stress induced by free iron. Expansion of these macrophages is seen in more than 30% of SJIA patients perhaps representing early stages of MAS. Recent gene expression studies linked expansion of these macrophages to distinct signatures. SUMMARY Recent advances in understanding of pathophysiologic conditions that favor expansion of hemophagocytic macrophages provide a source of new MAS biomarkers with applicability to clinical practice.
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Affiliation(s)
- Alexei A Grom
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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42
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Aronson IK, Worobec SM. Cytophagic histiocytic panniculitis and hemophagocytic lymphohistiocytosis: an overview. Dermatol Ther 2010; 23:389-402. [DOI: 10.1111/j.1529-8019.2010.01339.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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