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Hughes AD, Teachey DT, Diorio C. Riding the storm: managing cytokine-related toxicities in CAR-T cell therapy. Semin Immunopathol 2024; 46:5. [PMID: 39012374 PMCID: PMC11252192 DOI: 10.1007/s00281-024-01013-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/18/2024] [Indexed: 07/17/2024]
Abstract
The advent of chimeric antigen receptor T cells (CAR-T) has been a paradigm shift in cancer immunotherapeutics, with remarkable outcomes reported for a growing catalog of malignancies. While CAR-T are highly effective in multiple diseases, salvaging patients who were considered incurable, they have unique toxicities which can be life-threatening. Understanding the biology and risk factors for these toxicities has led to targeted treatment approaches which can mitigate them successfully. The three toxicities of particular interest are cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and immune effector cell-associated hemophagocytic lymphohistiocytosis (HLH)-like syndrome (IEC-HS). Each of these is characterized by cytokine storm and hyperinflammation; however, they differ mechanistically with regard to the cytokines and immune cells that drive the pathophysiology. We summarize the current state of the field of CAR-T-associated toxicities, focusing on underlying biology and how this informs toxicity management and prevention. We also highlight several emerging agents showing promise in preclinical models and the clinic. Many of these established and emerging agents do not appear to impact the anti-tumor function of CAR-T, opening the door to additional and wider CAR-T applications.
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Affiliation(s)
- Andrew D Hughes
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Caroline Diorio
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Jorisch-Mühlebach O, Pitts D, Tinner R, Teh HY, Roelli C, Prader S, Vavassori S, Pachlopnik Schmid J. A degranulation assay using Vγ9Vδ2 T cells for the rapid diagnosis of familial hemophagocytic syndromes. Front Immunol 2024; 15:1391967. [PMID: 38989281 PMCID: PMC11233720 DOI: 10.3389/fimmu.2024.1391967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/06/2024] [Indexed: 07/12/2024] Open
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune disorder characterized by uncontrolled lymphocyte and macrophage activation and a subsequent cytokine storm. The timely initiation of immunosuppressive treatment is crucial for survival. Methods Here, we harnessed Vγ9Vδ2 T cell degranulation to develop a novel functional assay for the diagnosis of HLH. We compared the novel assay with the conventional natural killer (NK) cell stimulation method in terms of efficiency, specificity, and reliability. Our analysis involved 213 samples from 182 individuals, including 23 samples from 12 patients with degranulation deficiency (10 individuals with UNC13D deficiency, 1 with STXBP2 deficiency, and 1 with RAB27A deficiency). Results While both tests exhibited 100% sensitivity, the Vγ9Vδ2 T cell degranulation assay showed a superior specificity of 86.2% (n=70) compared to the NK cell degranulation assay, which achieved 78.9% specificity (n=213). The Vγ9Vδ2 T cell degranulation assay offered simpler technical requirements and reduced labor intensity, leading to decreased susceptibility to errors with faster processing times. Discussion This efficiency stemmed from the sole requirement of dissolving (E)-4-hydroxy-3-methyl-but-2-enyl pyrophosphate (HMBPP) powder, contrasting with the intricate maintenance of K562 cells necessary for the NK cell degranulation assay. With its diminished susceptibility to errors, we anticipate that the assay will require fewer repetitions of analysis, rendering it particularly well-suited for testing infants. Conclusion The Vγ9Vδ2 T cell degranulation assay is a user-friendly, efficient diagnostic tool for HLH. It offers greater specificity, reliability, and practicality than established methods. We believe that our present findings will facilitate the prompt, accurate diagnosis of HLH and thus enable rapid treatment and better patient outcomes.
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MESH Headings
- Humans
- Lymphohistiocytosis, Hemophagocytic/diagnosis
- Lymphohistiocytosis, Hemophagocytic/immunology
- Lymphohistiocytosis, Hemophagocytic/genetics
- Cell Degranulation
- Female
- Male
- Killer Cells, Natural/immunology
- Killer Cells, Natural/metabolism
- Receptors, Antigen, T-Cell, gamma-delta/metabolism
- Receptors, Antigen, T-Cell, gamma-delta/genetics
- Child, Preschool
- Child
- Infant
- Adolescent
- rab27 GTP-Binding Proteins/genetics
- Membrane Proteins/genetics
- Membrane Proteins/metabolism
- Adult
- T-Lymphocytes/immunology
- Reproducibility of Results
- Lymphocyte Activation
- Sensitivity and Specificity
- Munc18 Proteins
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Affiliation(s)
- Olivia Jorisch-Mühlebach
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Dina Pitts
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Raphaela Tinner
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hong Ying Teh
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Conrad Roelli
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Seraina Prader
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Stefano Vavassori
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jana Pachlopnik Schmid
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Pediatric Immunology, University of Zurich, Zurich, Switzerland
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Elgaali E, Mezzavilla M, Ahmed I, Elanbari M, Ali A, Abdelaziz G, Fakhro KA, Saleh A, Ben-Omran T, Almulla N, Cugno C. Genetic background of primary and familial HLH in Qatar: registry data and population study. Front Pediatr 2024; 12:1326489. [PMID: 38808104 PMCID: PMC11130942 DOI: 10.3389/fped.2024.1326489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/08/2024] [Indexed: 05/30/2024] Open
Abstract
Background Familial hemophagocytic lymphohistiocytosis (FHLH) is an inherited life-threatening disease. Five types are identified, with the addition of congenital immunodeficiency syndromes in which HLH is a typical manifestation. The literature on this disease is very scarce in the Middle East, with only a few scattered reports. Methods We report detailed demographic, clinical, and genomic data from 28 patients diagnosed with primary and familial HLH over the last decade in Qatar. An evaluation was performed of allele frequencies of deleterious variants from 12 primary and familial HLH causative genes on the Qatar Genome Programme (QGP) cohort of 14,669 Qatari individuals. Results The genetic diagnosis was obtained in 15 patients, and four novel mutations in Perforin 1 (PRF1), UNC13D, LYST, and RAB27A genes were found. We identified 22,945 low/high/moderate/modifier impact variants significantly enriched in the QGP in those 12 genes. The variants rs1271079313 in PRF1 and rs753966933 in RAB27A found in our patient cohort were significantly more prevalent in the QGP compared to the Genome Aggregation Database (gnomAD) database, with a high carrier frequency in the Qatari population. Conclusions We established the first primary and familial HLH Registry in the Gulf Region and identified novel possibly pathogenic variants present at higher frequency in the Qatari population, which could be used for screening purposes. Raising awareness about primary and familial HLH and implementing screening activities in the Qatari highly inbred population could stem into more comprehensive premarital and prenatal evaluations and faster diagnosis.
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Affiliation(s)
- Elkhansa Elgaali
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
| | | | - Ikhlak Ahmed
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Aesha Ali
- Research Department, Sidra Medicine, Doha, Qatar
| | | | | | - Ayman Saleh
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
| | - Tawfeg Ben-Omran
- Division of Genetic and Genomic Medicine, Sidra Medicine, Doha, Qatar
- Department of Medical Genetics, Hamad Medical Corporation, Doha, Qatar
| | - Naima Almulla
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
| | - Chiara Cugno
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
- Research Department, Sidra Medicine, Doha, Qatar
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Böhm S, Wustrau K, Pachlopnik Schmid J, Prader S, Ahlmann M, Yacobovich J, Beier R, Speckmann C, Behnisch W, Ifversen M, Jordan M, Marsh R, Naumann-Bartsch N, Mauz-Körholz C, Hönig M, Schulz A, Malinowska I, Hines M, Nichols KE, Gil-Herrera J, Talano JA, Crooks B, Formankova R, Jorch N, Bakhtiar S, Kühnle I, Streiter M, Nathrath M, Russo A, Dürken M, Lang P, Lindemans C, Henter JI, Lehmberg K, Ehl S. Survival in primary hemophagocytic lymphohistiocytosis, 2016 to 2021: etoposide is better than its reputation. Blood 2024; 143:872-881. [PMID: 37992218 DOI: 10.1182/blood.2023022281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/24/2023] Open
Abstract
ABSTRACT Primary hemophagocytic lymphohistiocytosis (pHLH) is a life-threatening hyperinflammatory syndrome that develops mainly in patients with genetic disorders of lymphocyte cytotoxicity and X-linked lymphoproliferative syndromes. Previous studies with etoposide-based treatment followed by hematopoetic stem cell transplantation (HSCT) resulted in 5-year survival of 50% to 59%. Contemporary data are lacking. We evaluated 88 patients with pHLH documented in the international HLH registry from 2016-2021. In 12 of 88 patients, diagnosis was made without HLH activity, based on siblings or albinism. Major HLH-directed drugs (etoposide, antithymocyte globulin, alemtuzumab, emapalumab, ruxolitinib) were administered to 66 of 76 patients who were symptomatic (86% first-line etoposide); 16 of 57 patients treated with etoposide and 3 of 9 with other first-line treatment received salvage therapy. HSCT was performed in 75 patients; 7 patients died before HSCT. Three-year probability of survival (pSU) was 82% (confidence interval [CI], 72%-88%) for the entire cohort and 77% (CI, 64%-86%) for patients receiving first-line etoposide. Compared with the HLH-2004 study, both pre-HSCT and post-HSCT survival of patients receiving first-line etoposide improved, 83% to 91% and 70% to 88%. Differences to HLH-2004 included preferential use of reduced-toxicity conditioning and reduced time from diagnosis to HSCT (from 148 to 88 days). Three-year pSU was lower with haploidentical (4 of 9 patients [44%]) than with other donors (62 of 66 [94%]; P < .001). Importantly, early HSCT for patients who were asymptomatic resulted in 100% survival, emphasizing the potential benefit of newborn screening. This contemporary standard-of-care study of patients with pHLH reveals that first-line etoposide-based therapy is better than previously reported, providing a benchmark for novel treatment regimes.
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Affiliation(s)
- Svea Böhm
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
| | - Katharina Wustrau
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Jana Pachlopnik Schmid
- Division of Immunology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Pediatric Immunology, University Children's Hospital Zurich-Eleonorenstiftung, Zürich, Switzerland
| | - Seraina Prader
- Division of Immunology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Pediatric Immunology, University Children's Hospital Zurich-Eleonorenstiftung, Zürich, Switzerland
| | - Martina Ahlmann
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Joanne Yacobovich
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Tel Aviv Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Rita Beier
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Carsten Speckmann
- Division of Pediatric Hematology and Oncology Faculty of Medicine, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Behnisch
- Center for Pediatrics and Adolescent Medicine, Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rebecca Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nora Naumann-Bartsch
- Clinic for Children and Adolescents, University Clinic Erlangen, Erlangen, Germany
| | - Christine Mauz-Körholz
- Pediatric Hematooncology, University Children's Hospital Giessen, Giessen, Germany
- Medical Faculty, Martin-Luther University of Halle-Wittenberg, Halle, Germany
| | - Manfred Hönig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Iwona Malinowska
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Melissa Hines
- Division of Critical Care, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Kim E Nichols
- Division of Critical Care, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Juana Gil-Herrera
- Immunology, Hospital General Universitario and Instituto de Investigación Sanitaria "Gregorio Marañón," Madrid, Spain
| | - Julie-An Talano
- Pediatric Hematology/Oncology/Blood and Marrow Transplant Division, Medical College of Wisconsin, Madison, WI
| | - Bruce Crooks
- Paediatric Haematology/Oncology, IWK Health Centre, Halifax, NS, Canada
| | - Renata Formankova
- Department of Pediatric Haematology and Oncology, University Hospital Motol Prague, Prague, Czech Republic
| | - Norbert Jorch
- Bielefeld University, University Clinic for Pediatrics, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Shahrzad Bakhtiar
- Center for Pediatric and Adolescent Medicine, Frankfurt University Hospital, Frankfurt, Germany
| | - Ingrid Kühnle
- Division of Pediatric Hematology and Oncology, Göttingen University Medical Center, Göttingen, Germany
| | - Monika Streiter
- Clinic for Pediatrics and Adolescent Medicine, Hematology/Oncology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Michaela Nathrath
- Pediatric Hematology and Oncology, Psychosomatics and Systemic Diseases, Kassel Hospital, Kassel, Germany
- Department of Pediatrics and Children's Cancer Research Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexandra Russo
- Center for Pediatric and Adolescent Medicine, Pediatric Hematology/Oncology, University of Mainz, Mainz, Germany
| | - Matthias Dürken
- Department of Pediatrics and Adolescent Medicine, Mannheim University Hospital, Mannheim, Germany
| | - Peter Lang
- Clinic for Children and Adolescents, Department I Hematology/Oncology, Tübingen University Hospital, Tübingen, Germany
| | - Caroline Lindemans
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center, Utrecht, The Netherlands
| | - Jan-Inge Henter
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Alroqi FJ, Alhezam MA, Almojali AI, Barhoumi T, Althubaiti N, Alharbi Y, Al Balwi MA, Alrasheed A. Novel Presentation of Major Histocompatibility Complex Class II Deficiency with Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2024; 44:73. [PMID: 38424321 PMCID: PMC10904449 DOI: 10.1007/s10875-024-01674-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Major histocompatibility complex (MHC) class II deficiency is one of the combined immune deficiency disorders caused by defects in the MHC class II regulatory genes leading to abnormal T cells development and function. Therefore, patients mainly present with increased susceptibility to infections, diarrhea, and failure to thrive. In this report, we present one MHC class II deficient patient with a novel presentation with Hemophagocytic Lymphohistiocytosis (HLH). METHODS Immunophenotyping of lymphocyte subpopulations and HLA-DR expression was assess by flow cytometry. Gene mutational analysis was performed by whole exome and Sanger sequencing. RESULTS We reported a 7-year-old girl, who was diagnosed at age of 2 years with MHC class II deficiency by genetic testing and flow cytometry. Two years later, she developed disseminated BCGitis which was treated with proper antimicrobial agents. At the age of 7 years, she presented with clinical features fulfilling 6 diagnostic criteria of HLH including evidence of hemophagocytic activity in bone marrow aspiration. Accordingly, the diagnosis of HLH was established and the patient was started on IV Dexamethasone, Anakinra and IVIG. Eventually, patient started to improve and was discharged in good condition. Few months later, the patient was readmitted with severe pneumonia and sepsis leading to death. CONCLUSION Patients with MHC class II deficiency might present with disseminated BCGitis especially if the patient has severe T cell lymphopenia. Additionally, this immune defect might be added to the list of inborn errors of immunity that can be complicated with HLH.
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Affiliation(s)
- Fayhan J Alroqi
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City, Riyadh, 14611, Saudi Arabia.
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia.
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia.
| | - Musaab A Alhezam
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia
| | - Abdullah I Almojali
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia
- Division of Pediatric Rheumatology, Department of Pediatrics, King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City, Riyadh, 14611, Saudi Arabia
| | - Tlili Barhoumi
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
| | - Nouf Althubaiti
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
| | - Yousef Alharbi
- Pathology and Laboratory Medicine Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, 14611, Saudi Arabia
| | - Mohammed A Al Balwi
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia
- Pathology and Laboratory Medicine Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, 14611, Saudi Arabia
| | - Abdulrahman Alrasheed
- King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia
- Division of Pediatric Rheumatology, Department of Pediatrics, King Abdullah Specialized Children's Hospital, King Abdulaziz Medical City, Riyadh, 14611, Saudi Arabia
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Hirsch W, Megna B, Adeyi O, Lim N. Macrophage activation syndrome with acute hepatitis in a patient with adult-onset immunodeficiency with anti-interferon gamma antibodies: a case report. J Med Case Rep 2024; 18:6. [PMID: 38178160 PMCID: PMC10768153 DOI: 10.1186/s13256-023-04245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/05/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Macrophage activation syndrome is a rare disorder leading to unregulated immune activity manifesting with nonspecific constitutional symptoms, laboratory abnormalities, and multiorgan involvement. We report the case of a patient who presented with acute hepatitis secondary to macrophage activation syndrome diagnosed by liver biopsy and successfully treated with intravenous immune globulin, anakinra, and rituximab. CASE PRESENTATION A 42-year-old Laotian woman with adult-onset immunodeficiency with anti-interferon gamma antibodies presented with a fever, headache, generalized myalgia, dark urine, and reduced appetite in the setting of family members at home with similar symptoms. Her laboratory workup was notable for evidence of acute hepatitis without acute liver failure. After an unrevealing comprehensive infectious and noninvasive rheumatologic workup was completed, a liver biopsy was performed ultimately revealing the diagnosis of macrophage activation syndrome. She was successfully treated with intravenous immune globulin, anakinra, and rituximab. CONCLUSION This case highlights the importance of maintaining macrophage activation syndrome on the differential of a patient with acute hepatitis of unknown etiology in the correct clinical context and the value of a liver biopsy in making a diagnosis when noninvasive testing is unrevealing.
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Affiliation(s)
- William Hirsch
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Bryant Megna
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Oyedele Adeyi
- Department of Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Bloch C, Jais JP, Gil M, Boubaya M, Lepelletier Y, Bader-Meunier B, Mahlaoui N, Garcelon N, Lambotte O, Launay D, Larroche C, Lazaro E, Liffermann F, Lortholary O, Michel M, Michot JM, Morel P, Cheminant M, Suarez F, Terriou L, Urbanski G, Viallard JF, Alcais A, Fischer A, de Saint Basile G, Hermine O. Severe adult hemophagocytic lymphohistiocytosis (HLHa) correlates with HLH-related gene variants. J Allergy Clin Immunol 2024; 153:256-264. [PMID: 37678575 DOI: 10.1016/j.jaci.2023.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/14/2023] [Accepted: 07/14/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND The contribution of genetic factors to the severity of adult hemophagocytic lymphohistiocytosis (HLHa) remains unclear. OBJECTIVE We sought to assess a potential link between HLHa outcomes and HLH-related gene variants. METHODS Clinical characteristics of 130 HLHa patients (age ≥ 18 years and HScore ≥ 169) and genotype of 8 HLH-related genes (LYST, PRF1, UNC13-D, STX11, STXBP2, RAB27A, XIAP, and SAP) were collected. A total of 34 variants found in only 6 genes were selected on the basis of their frequency and criteria predicted to impair protein function. Severity was defined by refractory disease to HLH treatment, death, or transfer to an intensive care unit. RESULTS HLHa-associated diseases (ADs) were neoplasia (n = 49 [37.7%]), autoimmune/inflammatory disease (n = 33 [25.4%]), or idiopathic when no AD was identified (n = 48 [36.9%]). Infectious events occurred in 76 (58.5%) patients and were equally distributed in all ADs. Severe and refractory HLHa were observed in 80 (61.5%) and 64 (49.2%) patients, respectively. HScore, age, sex ratio, AD, and infectious events showed no significant association with HLHa severity. Variants were identified in 71 alleles and were present in 56 (43.1%) patients. They were distributed as follows: 44 (34.4%), 9 (6.9%), and 3 (2.3%) patients carrying 1, 2, and 3 variant alleles, respectively. In a logistic regression model, only the number of variants was significantly associated with HLHa severity (1 vs 0: 3.86 [1.73-9.14], P = .0008; 2-3 vs 0: 29.4 [3.62-3810], P = .0002) and refractoriness (1 vs 0: 2.47 [1.17-5.34], P = .018; 2-3 vs 0: 13.2 [2.91-126.8], P = .0003). CONCLUSIONS HLH-related gene variants may be key components to the severity and refractoriness of HLHa.
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Affiliation(s)
- Coralie Bloch
- Clinical Research Unit, Avicenne University Hospital, AP-HP, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, Paris, France; Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France.
| | - Jean Philippe Jais
- Imagine Institute, Université Paris Cité, Paris, France; Biostatistic Unit, Necker University Hospital, AP-HP, Paris, France; Human Genetics of Infectious Diseases: Complex Predisposition, INSERM UMR1163, Paris, France
| | - Marine Gil
- Imagine Institute, Université Paris Cité, Paris, France
| | - Marouane Boubaya
- Clinical Research Unit, Avicenne University Hospital, AP-HP, Bobigny, France
| | - Yves Lepelletier
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; Imagine Institute, Université Paris Cité, Paris, France
| | - Brigitte Bader-Meunier
- Imagine Institute, Université Paris Cité, Paris, France; Department of Pediatric Immunology and Rheumatology, Necker University Hospital, AP-HP, Paris, France
| | - Nizar Mahlaoui
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Department of Pediatric Immunology and Rheumatology, Necker University Hospital, AP-HP, Paris, France
| | | | - Olivier Lambotte
- University Paris Saclay, AP-HP, Hôpital Bicêtre, IMVAHB UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - David Launay
- Université de Lille, CHU Lille, Département de Médecine Interne et Immunologie Clinique, Centre de Référence des Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France, Lille, France; INSERM INFINITE U1286, Lille, France
| | - Claire Larroche
- Internal Medicine Unit, Avicenne Hospital, AP-HP, Bobigny, France
| | - Estibaliz Lazaro
- Internal Medicine Department, Bordeaux Hospital University, Bordeaux, France; CNRS-UMR 5164 Immuno ConcEpT, Bordeaux, France
| | - Francois Liffermann
- Service de medecine interne-hematologie, Centre hospitalier de Dax, Dax, France
| | - Olivier Lortholary
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Service de Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker Pasteur, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Marc Michel
- Department of Internal Medicine, Centre de Référence maladies rares sur les Cytopénies Auto-Immunes de l'adulte, Hôpitaux Universitaires Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Jean-Marie Michot
- Gustave Roussy, University Paris Saclay, Drug Development Department, Villejuif, France
| | - Pierre Morel
- Service d'Hématologie Clinique, Hôpital Schaffner de Lens, Lens Cedex, France
| | - Morgane Cheminant
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Clinical Hematology, Necker University Hospital, AP-HP, Paris, France
| | - Felipe Suarez
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Clinical Hematology, Necker University Hospital, AP-HP, Paris, France
| | - Louis Terriou
- Université de Lille, CHU Lille, Département de Médecine Interne et Immunologie Clinique, Centre de Référence des Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France, Lille, France; INSERM INFINITE U1286, Lille, France
| | - Geoffrey Urbanski
- Department of Internal Medicine and Clinical Immunology, University Hospital, Angers, France; MitoLab Team, MITOVASC Institute, UMR CNRS 6015, INSERM U1083, University of Angers, Angers, France
| | | | - Alexandre Alcais
- Imagine Institute, Université Paris Cité, Paris, France; Biostatistic Unit, Necker University Hospital, AP-HP, Paris, France; Human Genetics of Infectious Diseases: Complex Predisposition, INSERM UMR1163, Paris, France
| | - Alain Fischer
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Department of Pediatric Immunology and Rheumatology, Necker University Hospital, AP-HP, Paris, France; Laboratory of Normal and Pathological Homeostasis of the Immune System, INSERM UMR1163, Paris, France; Necker University Hospital, AP-HP, Paris, France; College de France, Paris, France
| | - Geneviève de Saint Basile
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Laboratory of Normal and Pathological Homeostasis of the Immune System, INSERM UMR1163, Paris, France
| | - Olivier Hermine
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Clinical Hematology, Necker University Hospital, AP-HP, Paris, France.
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Geng F, Yang M, Zhang X, Zhao H, Zhou D, Hu J. Typical hemophagocytic syndrome associated with cytomegalovirus infection in an immunocompetent patient: a case report and literature review. J Zhejiang Univ Sci B 2023; 24:1159-1164. [PMID: 38057272 PMCID: PMC10710908 DOI: 10.1631/jzus.b2300232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/05/2023] [Indexed: 12/08/2023]
Abstract
Cytomegalovirus (CMV) infection is currently prevalent in populations throughout the world, and 56%-94% of the global population is seropositive for CMV. CMV infection mainly affects immunocompromised hosts. In these cases, it can cause significant symptoms, tissue-invasive disease, and many sequelae including death (Dioverti and Razonable, 2016). The vast majority of healthy adults with CMV infection experience an asymptomatic course; when symptomatic, it manifests as a mononucleosis-like syndrome in approximately 10% of patients (Sridhar et al., 2018). The gastrointestinal tract and central nervous system appear to be the most frequent sites of severe CMV infection in immunocompetent individuals (Rafailidis et al., 2008). However, CMV infection is relatively rarely recorded in immunocompetent hosts.
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Affiliation(s)
- Fangfang Geng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Meifang Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xuan Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hong Zhao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - De Zhou
- Department of Hematology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jianhua Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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9
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Hajji M, Barbouch S, Kaaroud H, Ben Abdelghani K, Ben Hamida F, Harzallah A, Abderrahim E. Uncovering the Spectrum of Hemophagocytic Lymphohistiocytosis: A Nephrology Department's Analysis of 14 Cases. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231210137. [PMID: 37920369 PMCID: PMC10619340 DOI: 10.1177/11795476231210137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/10/2023] [Indexed: 11/04/2023]
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a disease of multi-organ dysfunction due to excessive immune activation causing widespread inflammation and tissue destruction. It is a severe condition associated with high morbidity and mortality. Early identification is crucial for prompt treatment. The objective of this case series is to underscore the intricacy of managing HLH in individuals with renal dysfunction. Methods This is a retrospective study of patients diagnosed with HLH in a nephrology department over a period of 30 years. We retrospectively reviewed the medical files by applying the Revised HLH-2004 criteria. Results Among the 14 female patients included, the mean age was 45.2 years (range 23-78). Nine patients presented with sudden onset of fever and chills. Physical examination revealed purpura in 3 cases, hepatomegaly and splenomegaly in 6 and 5 cases respectively, and peripheral lymphadenopathy in 1 case. Hemorrhagic complications were observed in 5 cases, hypertriglyceridemia in 9 cases, and hyperferritinemia in all cases. Hypothyroidism was observed in all cases, and impaired renal function was detected in 11 of them, with 5 experiencing it as a result of lupus nephritis, and 1 case attributed to pre-eclampsia. Hemophagocytosis was confirmed through sternal puncture in 11 cases. Treatment involved etiological therapy with corticosteroids and immunosuppressants and/or anti-infectives. Intravenous immunoglobulins were administered in 6 cases, while 2 cases required coagulation factor transfusions. Unfortunately, 9 patients did not survive. Conclusion The study highlights the need for increased awareness and prompt recognition of HLH, particularly in patients with associated renal complications.
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Affiliation(s)
- Meriam Hajji
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Samia Barbouch
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Hayet Kaaroud
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Khaoula Ben Abdelghani
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Amel Harzallah
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Ezzeddine Abderrahim
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
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10
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Luo X, Zhou C, Ji C, Lu C, Luo Y, Chen Z, Zhong T, Ye R, Zeng L, Luo M. Hypofibrinogenemia is an independent predictor of hemophagocytic lymphohistiocytosis in children with sepsis. Sci Rep 2023; 13:17936. [PMID: 37863910 PMCID: PMC10589207 DOI: 10.1038/s41598-023-44628-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 10/10/2023] [Indexed: 10/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening condition in children with sepsis. We herein aimed to identify clinical and laboratory predictors of HLH in children with sepsis. We conducted a retrospective study of 568 children with sepsis admitted to Guangdong Women and Children Hospital from January 2019 to June 2022. HLH, while rare (6.34%), proved to be a highly fatal complication (37.14%) in children with sepsis. Children with HLH had higher levels of aspartate aminotransferase, lactate dehydrogenase, triglycerides, and ferritin than children without HLH; conversely, they displayed decreased levels of neutrophils, hemoglobin, platelets, fibrinogen, and albumin. Additionally, the HLH group showed higher rates of prolonged fever (> 10 days), hepatomegaly, and splenomegaly than the non-HLH group. Our retrospective analysis identified hypofibrinogenemia (OR = 0.440, P = 0.024) as an independent predictor for the development of HLH in patients with sepsis. The optimal cutoff value for fibrinogen was found to be < 2.43 g/L. The area under the curve for diagnosing HLH was 0.80 (95% confidence interval: 0.73-0.87, P < 0.0001), with a sensitivity of 72.41% and specificity of 76.27%. Thus, hypofibrinogenemia emerges as a potentially valuable predictor for HLH in children with sepsis.
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Affiliation(s)
- Xin Luo
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Chentao Zhou
- Laboratory Medicine, Medical College of Jiaying University, Guangzhou, 511400, People's Republic of China
| | - Cunwei Ji
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Chunmin Lu
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Yasha Luo
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Zhenhui Chen
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Tianhua Zhong
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Ruoting Ye
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Liwei Zeng
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Mingyong Luo
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China.
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11
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Dong Y, Gao R, He K, Zhong J, Dong L. The Role of the IL-33/ST2 Axis in CpG-Induced Macrophage Activation Syndrome. J Immunol Res 2023; 2023:2689360. [PMID: 37842289 PMCID: PMC10569892 DOI: 10.1155/2023/2689360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 03/26/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023] Open
Abstract
Background Macrophage activation syndrome (MAS) is a fatal inflammatory condition, which is often associated with the elevation of multiple proinflammatory cytokines and multiple organ dysfunction. Previous studies have shown that ST2 contributes to T cell overactivation and plays a detrimental role in mouse models of primary hemophagocytic lymphohistiocytosis. The purpose of this study was to investigate the role of the IL-33/ST2 axis in a mouse model of MAS induced by repeated injections of cytosine-phosphate-guanine (CpG). Methods Serum cytokines were determined using the cytometric bead array by flow cytometry. IL-33 and ST2 were detected by immunohistochemistry and real-time quantitative PCR in the liver and spleen of mice. CD3 and F4/80 in the liver were detected by immunohistochemistry. Inflammatory macrophages and effector memory T lymphocytes were detected by flow cytometry. Result The CpG-induced MAS model was successfully induced after repeated CpG injections, presenting with hypercytokinemia and hepatosplenomegaly. The numbers of IL-33 positive cells in the liver and spleen decreased significantly, while the expression of ST2 in the liver tended to increase in the mice with MAS. IL-33 and St2 knockout mice showed similar levels of hepatosplenomegaly, peripheral blood count, and cytokine storm when compared with wild-type (WT) mice after induction of MAS. There were also no significant differences in liver pathology (including inflammatory cell infiltration of CD3 and F4/80) and levels of splenic inflammatory macrophages and effector memory T cells between the WT and knockout mice. Conclusion These results suggested that IL-33 decreased in the liver and spleen tissues of MAS mice. Further results suggest that IL-33 and St2 knockout mice have no treatment potential in CpG-induced MAS. Thus, the IL-33/ST2 axis has little effect on the prognosis of CpG-induced MAS.
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Affiliation(s)
- Yuanji Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Rongfen Gao
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kailin He
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jixin Zhong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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12
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Sienes Bailo P, Goñi Ros N, Menéndez Jándula B, Álvarez Alegret R, González Gómez E, González Tarancón R, Izquierdo Álvarez S. First case of very late-onset FHL2 in Spain with two variants in the PRF1 gene. Ann Clin Biochem 2023; 60:356-364. [PMID: 37365821 DOI: 10.1177/00045632231186076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but fatal disorder characterized by the proliferation and infiltration of macrophages and hyperactivated T lymphocytes that escape from the physiological control pathways and favour the existence of an environment of excessive inflammation and tissue destruction. HLH has been classified into two types: a primary or familial autosomal recessive form, caused by mutations in genes encoding proteins involved in the granule-dependent cytotoxic pathway (familial hemophagocytic lymphohistiocytosis [FHL] types 1-5); and other secondary or acquired form, generally associated with infections, malignancy, autoimmune diseases, metabolic disorders or primary immunodeficiencies. Since the first familial hemophagocytic lymphohistiocytosis-2 (FHL2) causative mutation in the PRF1 gene was described in 1999, more than 200 mutations have been identified to date. Here, we report the first case of very late-onset FHL2 in a Spanish 72-year-old female with splenomegaly, hypertriglyceridemia, hypofibrinogenemia, pancytopenia and marrow hemophagocytosis harbouring in heterozygosity two PRF1 variants proposed as causative in this study. The heterozygous mutation c.445G>A (p.Gly149Ser) identified in the exon 2 results in a missense mutation previously described as a probable pathogenic variant associated with the development of FHL2. Affecting the same exon, c.272C>T (p.Ala91Val) is the most prevalent variant of this gene. Although it was initially classified as benign, recent studies support its potential pathogenic role, considering it a variant of uncertain significance associated with a risk of developing FHL2. The genetic confirmation of FHL made possible an adequate counselling to the patient and direct relatives and provided important information for her control and follow-up.
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Affiliation(s)
- Paula Sienes Bailo
- Department of Clinical Biochemistry and Clinical Genetics, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Nuria Goñi Ros
- Department of Clinical Biochemistry and Clinical Genetics, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | | | - Ricardo González Tarancón
- Department of Clinical Biochemistry and Clinical Genetics, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Silvia Izquierdo Álvarez
- Department of Clinical Biochemistry and Clinical Genetics, Hospital Universitario Miguel Servet, Zaragoza, Spain
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13
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Hines MR, Knight TE, McNerney KO, Leick MB, Jain T, Ahmed S, Frigault MJ, Hill JA, Jain MD, Johnson WT, Lin Y, Mahadeo KM, Maron GM, Marsh RA, Neelapu SS, Nikiforow S, Ombrello AK, Shah NN, Talleur AC, Turicek D, Vatsayan A, Wong SW, Maus MV, Komanduri KV, Berliner N, Henter JI, Perales MA, Frey NV, Teachey DT, Frank MJ, Shah NN. Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like Syndrome. Transplant Cell Ther 2023; 29:438.e1-438.e16. [PMID: 36906275 PMCID: PMC10330221 DOI: 10.1016/j.jtct.2023.03.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/20/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023]
Abstract
T cell-mediated hyperinflammatory responses, such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), are now well-established toxicities of chimeric antigen receptor (CAR) T cell therapy. As the field of CAR T cells advances, however, there is increasing recognition that hemophagocytic lymphohistiocytosis (HLH)-like toxicities following CAR T cell infusion are occurring broadly across patient populations and CAR T cell constructs. Importantly, these HLH-like toxicities are often not as directly associated with CRS and/or its severity as initially described. This emergent toxicity, however ill-defined, is associated with life-threatening complications, creating an urgent need for improved identification and optimal management. With the goal of improving patient outcomes and formulating a framework to characterize and study this HLH-like syndrome, we established an American Society for Transplantation and Cellular Therapy panel composed of experts in primary and secondary HLH, pediatric and adult HLH, infectious disease, rheumatology and hematology, oncology, and cellular therapy. Through this effort, we provide an overview of the underlying biology of classical primary and secondary HLH, explore its relationship with similar manifestations following CAR T cell infusions, and propose the term "immune effector cell-associated HLH-like syndrome (IEC-HS)" to describe this emergent toxicity. We also delineate a framework for identifying IEC-HS and put forward a grading schema that can be used to assess severity and facilitate cross-trial comparisons. Additionally, given the critical need to optimize outcomes for patients experiencing IEC-HS, we provide insight into potential treatment approaches and strategies to optimize supportive care and delineate alternate etiologies that should be considered in a patient presenting with IEC-HS. By collectively defining IEC-HS as a hyperinflammatory toxicity, we can now embark on further study of the pathophysiology underlying this toxicity profile and make strides toward a more comprehensive assessment and treatment approach.
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Affiliation(s)
- Melissa R Hines
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tristan E Knight
- Pediatric Hematology and Oncology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington
| | - Kevin O McNerney
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Mark B Leick
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Sairah Ahmed
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Frigault
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - William T Johnson
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yi Lin
- Division Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota
| | - Kris M Mahadeo
- Pediatric Transplantation and Cellular Therapy, Duke University, Durham, North Carolina
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - Rebecca A Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sattva S Neelapu
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah Nikiforow
- Division of Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Amanda K Ombrello
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirav N Shah
- Bone Marrow Transplant and Cellular Therapy Program, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - David Turicek
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Anant Vatsayan
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Sandy W Wong
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Marcela V Maus
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Krishna V Komanduri
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | | | - Jan-Inge Henter
- Division of Pediatric Oncology and Surgery, Department of Women's and Children's Health, Karolinska Institute, and Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noelle V Frey
- Division of Hematology-Oncology, Abramson Cancer Center and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David T Teachey
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Frank
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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14
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Yang Y, Yu H, Li C, Gui Z, Chang Y. Specific cytokine patterns in Epstein-Barr virusassociated hemophagocytic lymphohistiocytosis compared to Kawasaki disease in children. Pediatr Hematol Oncol 2023; 40:529-538. [PMID: 37178062 DOI: 10.1080/08880018.2023.2186555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 05/15/2023]
Abstract
The aim of the study was to test whether the cytokine profile could be used as a marker to differentiate between Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH) and Kawasaki disease (KD). A total of 70 hospitalized children with HLH and KD admitted to hospital for the first time from March 2017 to December 2021 were enrolled in this study. Fifty-five healthy children were enrolled as normal controls. All patients and normal controls were tested for the six cytokines including interleukin-2 (IL-2), interleukin-4 (IL-4), interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-α), and interferon-γ (IFN-γ) by flow cytometry. IL-10 and IFN-γ levels were significantly higher in children with EBV-HLH than in the KD, IL-6 was lower in EBV-HLH patients than in the KD. IL-10/IL-6 ratio, IFN-γ/IL-6 ratio and IL10/IFN-γ ratio in children with EBV-HLH were significantly much higher than children in the KD group. When the diagnostic cutoff values of IL-10, IFN-γ, IL-10/IL-6 ratio and IFN-γ/IL-6 ratio were >13.2 pg/ml, >71.0 pg/ml, >0.37 and >1.34, respectively, the sensitivity and specificity of the diagnosis of EBV-HLH disease were 91.7% and 97.1%, 72.2% and 97.1%, 86.1% and 100.0%, and 75.0% and 97.1%, respectively. Notably high IL-10 and IFN-γ and moderately elevated IL-6 suggest the diagnosis of EBV-HLH, while high IL-6 levels with low IL-10 or IFN-γ concentration would suggest KD. Additionally, IL-10/IL-6 ratio or IFN-γ/IL-6 ratio could be used as an index to differentiate between EBV-HLH and KD.
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Affiliation(s)
- Yanli Yang
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hanqing Yu
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chenli Li
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Gui
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Chang
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
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Sacco KA, Notarangelo LD, Delmonte OM. When to suspect inborn errors of immunity in Epstein-Barr virus-related lymphoproliferative disorders. Clin Microbiol Infect 2023; 29:457-462. [PMID: 36209991 PMCID: PMC10066820 DOI: 10.1016/j.cmi.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/20/2022] [Accepted: 10/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND More than 95% of humans have been infected with Epstein-Barr virus (EBV) and develop anti-EBV IgG antibodies, conferring immunity. However, among specific populations, EBV may induce a range of B-cell lymphoproliferative disorders (LPDs). EBV may also contribute to T-cell and natural killer (NK)-cell lymphoproliferation. The immune system is essential to prevent infection and development of cancer. Inborn errors of immunity (IEIs) are a heterogenous group of more than 450 genetic disorders predisposing to severe and/or recurrent infection, autoimmunity, autoinflammation, or early-onset/severe neoplasia or lymphoproliferation. Monogenic disorders of T-cell and B-cell signalling are classic IEIs that predispose to EBV-associated LPDs. OBJECTIVES We aimed to outline the various clinical manifestations of EBV-associated LPDs and the underlying IEIs associated with such presentations and discuss the recommended management and therapeutic options pertaining to these disorders. SOURCES We searched PubMed, Embase, and Web of Science Core Collection on 30 September 2021. Clinical studies, systematic reviews, narrative reviews, and case reports were identified through search strategy and cross reference from primary literature. CONTENT Effective T-cell and NK-cell cytotoxicity towards EBV-infected B cells relies on intact MAGT1-dependent NKG2D pathways and signalling lymphocyte activation molecular-associated protein-dependent signalling lymphocyte activation molecular receptors. The interaction between CD27 and CD70 is also critical to drive the expansion of EBV-specific T cells. IEIs due to T-cell and B-cell signalling defects and/or impaired T-cell and NK-cell cytotoxicity predispose to EBV-related lymphoproliferation. This includes classic disorders such as X-linked lymphoproliferative disease 1 (due to SH2D1A mutations), X-linked lymphoproliferative disease 2 (XIAP), and other genetic diseases, such as ITK, MAGT1, CD27, CD70, CTPS1, RASGRP1, and CORO1A deficiencies. EBV-driven lymphoproliferation may manifest to a lesser degree in MST1/STK4, DOCK8, STIM1, CORO1A, IL21R, PIK3CD gain-of-function, and PI3KR1 deficiencies. IMPLICATIONS Early screening for IEIs is indicated in cases of EBV-related lymphoproliferation because different forms of IEIs have specific prognostic and therapeutic implications.
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Affiliation(s)
- Keith A Sacco
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, USA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, USA
| | - Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, USA.
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Mechi AM, Al‐Khalidi AA, Hasan TA. Hemophagocytic Lymphohistiocytosis syndrome (HLH) associated with acute pancreatitis: A case report. Clin Case Rep 2023; 11:e7096. [PMID: 36950669 PMCID: PMC10025947 DOI: 10.1002/ccr3.7096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/22/2022] [Accepted: 10/19/2022] [Indexed: 03/24/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis syndrome is fatal hyper-inflammatory condition due to over-activation of the immune system, being of primary and secondary types. This case report emphasizes the difficulty and challenge in and of the HLH diagnosis, and therapy should be employed promptly given the high mortality associated with HLH.
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Affiliation(s)
- Ahmed Mohamad Mechi
- Internal Medicine Department, College of MedicineUniversity of KufaNajafIraq
| | - Alhan Abbas Al‐Khalidi
- Internal Medicine Department, College of MedicineJabir Ibn Hayyan Medical UniversityNajafIraq
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17
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Planas R, Felber M, Vavassori S, Pachlopnik Schmid J. The hyperinflammatory spectrum: from defects in cytotoxicity to cytokine control. Front Immunol 2023; 14:1163316. [PMID: 37187762 PMCID: PMC10175623 DOI: 10.3389/fimmu.2023.1163316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Cytotoxic lymphocytes kill target cells through polarized release of the content of cytotoxic granules towards the target cell. The importance of this cytotoxic pathway in immune regulation is evidenced by the severe and often fatal condition, known as hemophagocytic lymphohistiocytosis (HLH) that occurs in mice and humans with inborn errors of lymphocyte cytotoxic function. The clinical and preclinical data indicate that the damage seen in severe, virally triggered HLH is due to an overwhelming immune system reaction and not the direct effects of the virus per se. The main HLH-disease mechanism, which links impaired cytotoxicity to excessive release of pro-inflammatory cytokines is a prolongation of the synapse time between the cytotoxic effector cell and the target cell, which prompts the former to secrete larger amounts of cytokines (including interferon gamma) that activate macrophages. We and others have identified novel genetic HLH spectrum disorders. In the present update, we position these newly reported molecular causes, including CD48-haploinsufficiency and ZNFX1-deficiency, within the pathogenic pathways that lead to HLH. These genetic defects have consequences on the cellular level on a gradient model ranging from impaired lymphocyte cytotoxicity to intrinsic activation of macrophages and virally infected cells. Altogether, it is clear that target cells and macrophages may play an independent role and are not passive bystanders in the pathogenesis of HLH. Understanding these processes which lead to immune dysregulation may pave the way to novel ideas for medical intervention in HLH and virally triggered hypercytokinemia.
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Affiliation(s)
- Raquel Planas
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
- Department of Cell Biology, Physiology and Immunology, University of Barcelona, Barcelona, Spain
| | - Matthias Felber
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Stefano Vavassori
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Jana Pachlopnik Schmid
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Immunology, University of Zurich, Zurich, Switzerland
- *Correspondence: Jana Pachlopnik Schmid,
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18
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Practice patterns and outcomes of hemophagocytic lymphohistiocytosis in adults: a 2-decade provincial retrospective review. Ann Hematol 2022; 101:2297-2306. [PMID: 35978181 DOI: 10.1007/s00277-022-04960-2] [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: 04/18/2022] [Accepted: 08/13/2022] [Indexed: 11/01/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a heterogeneous, life-threatening clinical syndrome. There are scarce data on the quality of care in HLH or data comparing treatment patterns and outcomes between different triggers. We aimed to examine quality-of-care indicators and outcomes in adults with various HLH triggers. In this multi-centre retrospective cohort study of adult HLH in the province of Alberta, Canada (1999-2019), we examined quality indicators including diagnostic testing, time to diagnosis and treatment and trigger identification. We also compared treatment regimens and outcomes across HLH triggers. Logistic regression was used to identify predictors of etoposide use. Overall survival (OS) was estimated using the Kaplan-Meier method. We identified 97 patients; 66 (68%) were male. Triggers included malignancy (36%), infection (35%), autoimmune disease (21%) and idiopathic/others (8%). Specialized tests such as sCD25 (53%) and natural killer degranulation assay (19%) were under-performed, as were testing for infectious triggers. Etoposide was administered in only 33 (34%). Neutropenia, hyperbilirubinemia and hyperferritinemia, but not age, sex and comorbidities, were significant predictors of etoposide use. At median follow-up of 32 months, median OS was 18.8 months. Worse OS was seen in malignancy-associated and idiopathic HLH (log-rank P < 0.001). Our study showed low rates of specialized testing such as sCD25 and a low rate of etoposide use. Development of a standardized provincial protocol has the potential to improve quality of care in adult HLH.
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19
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Caldirola MS, Raccio AG, Giovanni DD, Gaillard MI, Preciado MV. Pediatric inborn errors of immunity causing hemophagocytic lymphohistiocytosis: Case report and review of the literature. J Leukoc Biol 2022; 112:607-615. [PMID: 35899932 DOI: 10.1002/jlb.5mr0622-037r] [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: 04/12/2022] [Revised: 06/28/2022] [Indexed: 11/07/2022] Open
Abstract
Inborn errors of immunity are a group of genetic disorders caused by mutations that affect the development and/or function of several compartments of the immune system, predisposing patients to infections, autoimmunity, allergy and malignancies. In this regard, mutations that affect proteins involved in trafficking, priming, docking, or membrane fusion will impair the exocytosis of lytic granules of effector NK and cytotoxic T lymphocytes. This may predispose patients to hemophagocytic lymphohistiocytosis, a life-threatening immune disorder characterized by systemic lymphocyte and macrophage activation, and increased levels of cytokines, which lead to an uncontrolled hyperinflammation state and progressive multiorgan damage. In this review, we will describe a clinical case and recent advances in inborn errors of immunity predisposing to hemophagocytic lymphohistiocytosis. Summary sentence: Review of recent advances in inborn errors of immunity predisposing to hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- María Soledad Caldirola
- Servicio Inmunología, Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP- CONICET-GCBA)- Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| | - Andrea Gómez Raccio
- Servicio de Inmunología, Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| | - Daniela Di Giovanni
- Servicio de Inmunología, Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| | - María Isabel Gaillard
- Servicio Inmunología, Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP- CONICET-GCBA)- Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina.,Sección Citometría - Laboratorio Stamboulian, Buenos Aires, Argentina
| | - María Victoria Preciado
- Laboratorio de Biología Molecular, División Patología, Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
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20
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Ren W, Yang S, Liu H, Pan Z, Li Z, Qiao P, Ma H. Case report and literature review: Hemophagocytic lymphohistiocytosis in a pregnant woman with systemic lupus erythematosus with Syntaxin 11 gene defect. Front Oncol 2022; 12:937494. [PMID: 35965579 PMCID: PMC9367683 DOI: 10.3389/fonc.2022.937494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is an extremely rare occurrence during pregnancy. Early recognition of its signs and symptoms is critical for early intervention, and delays in diagnosis may be life-threatening. A 23-year-old nulliparous woman presented with a persistent fever as high as 39°C with bilateral edema of the lower limbs at 24 weeks of gestation. Typical laboratory findings included pancytopenia, high triglycerides, ferritin, transaminases, bilirubin, and hypoproteinemia. Active systemic lupus erythematosus was diagnosed using an autoimmune work-up and a Systemic Lupus Erythematosus Disease Activity Index 2000 score of 17 points. Her bone marrow aspirate revealed prominent hemophagocytosis; hence, HLH was confirmed. Genetic tests showed mutations in Syntaxin 11 mutations. Considering the potential impact of drugs on the fetus, the patient and her family members chose to terminate the pregnancy through medical induction of labor. Afterwards, her condition improved with immunosuppressive therapy.
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Affiliation(s)
- Wei Ren
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Siyuan Yang
- College of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Haiying Liu
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhenglun Pan
- Department of Rheumatism and Immunology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhao Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Peng Qiao
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Peng Qiao, ; Hui Ma,
| | - Hui Ma
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Peng Qiao, ; Hui Ma,
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21
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Wang D, Chen XH, Wei A, Zhou CJ, Zhang X, Ma HH, Lian HY, Zhang L, Zhang Q, Huang XT, Wang CJ, Yang Y, Liu W, Wang TY, Li ZG, Cui L, Zhang R. Clinical features and treatment outcomes of pediatric Langerhans cell histiocytosis with macrophage activation syndrome-hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2022; 17:151. [PMID: 35379272 PMCID: PMC8981711 DOI: 10.1186/s13023-022-02276-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Langerhans cell histiocytosis (LCH) is a rare myeloid neoplasm. A few LCH patients had Macrophage activation syndrome-hemophagocytic lymphohistiocytosis (MAS-HLH), a life-threatening, hyper-inflammatory syndrome. We retrospectively described the clinical-biological characteristics of a series of 28 pediatric LCH patients with MAS-HLH in a single center. We further analyzed the difference in treatment outcomes between second-line chemotherapy (cytarabine and cladribine) and targeted therapy (dabrafenib) for BRAF-V600E-positive patients. Results LCH patients with MAS-HLH were aged < 2 years, harbored high frequencies of risk organ, skin, or lymph nodes involvement, and most of them carried BRAF-V600E mutation in lesions (88.0%) or plasma (90.5%). Patients were firstly treated with the initial induction first-line therapy (vindesine-steroid combination), and most of them (26/28) failed to control the active MAS-HLH after one six-week course of induction treatment. Then they were shifted to second-line chemotherapy or targeted therapy dabrafenib. BRAF-V600E-mutant patients treated with dabrafenib had prompt resolution of MAS-HLH signs and symptoms with less toxicity than second-line chemotherapy. Moreover, the progression-free survival (PFS) rate for patients given dabrafenib was much higher than those treated with chemotherapy (4 year-PFS: 75% vs. 14.6%, P = 0.034). Conclusions LCH patients with MAS-HLH harbored specific clinical-biology characteristics compared to the multisystem LCH without MAS-HLH. The BRAF inhibitor dabrafenib provides a promising treatment option for LCH with MAS-HLH. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02276-y.
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22
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Croden J, Bilston L, Taparia M, Grossman J, Sun HL. Incidence of bleeding and thromboembolism and impact on overall survival in adult patients with hemophagocytic lymphohistiocytosis: A 20-year provincial retrospective cohort study. J Thromb Haemost 2022; 20:671-683. [PMID: 34856055 DOI: 10.1111/jth.15615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome characterized by uncontrolled immune activation and high risk of death. There is scarce data on the incidence of bleeding and thromboembolism in HLH. OBJECTIVES To determine the cumulative incidence of bleeding and thromboembolism and impact on survival in adults with HLH. PATIENTS/METHODS We conducted a multicenter retrospective cohort study of adults with HLH in Alberta, Canada (1999-2019). The cumulative incidence of bleeding and thromboembolism were calculated, accounting for competing risks. Cox proportional hazards models were used to assess the impact of bleeding and thromboembolism on overall survival (OS). RESULTS We identified 97 adults with HLH (median age 46 years). Venous thromboembolism (VTE) occurred in 11 (11%) patients at a median of 9 days from admission. ISTH major bleeding and clinically relevant non-major bleeding occurred in 39 (40%) patients, at a median of 16 days after admission. Nadir platelet count (adjusted odds ratio [aOR] 1.8 per log decrease, 95% confidence interval [CI] 1.2-2.8) and mechanical ventilation (aOR 4.9, 95% CI 1.8-14.8) were independent predictors of bleeding on multivariable analysis. Adjusting for competing risks, the 90-day cumulative incidences of bleeding and thromboembolism were 39% and 13%, respectively. The median OS was 18.8 months. VTE, but not bleeding, was significantly associated with adverse OS (adjusted hazard ratio 2.5, 95% CI 1.1-5.7). CONCLUSIONS In adults with HLH, VTE appears more common than previously described and is a predictor of mortality, although this may be due to unadjusted confounding. VTE prevention and treatment are challenging due to high bleeding rates.
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Affiliation(s)
- Jennifer Croden
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Bilston
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Minakshi Taparia
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Grossman
- Division of Hematology and Bone Marrow Transplantation, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Haowei Linda Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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23
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Aichele P, Neumann-Haefelin C, Ehl S, Thimme R, Cathomen T, Boerries M, Hofmann M. Immunopathology caused by impaired CD8+ T cell responses. Eur J Immunol 2022; 52:1390-1395. [PMID: 35099807 DOI: 10.1002/eji.202149528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/16/2021] [Accepted: 01/24/2022] [Indexed: 11/12/2022]
Abstract
Recent findings indicate that many immunopathologies are at their roots a consequence of impaired immune responses ("too little" immunity) and not the result of primarily exaggerated immune responses ("too much" immunity). We have summarized this conceptional view as "IMPATH paradox". In this review, we will focus on impaired immune reactions in the context of CD8+ T cell-mediated immunopathologies. In particular, we will exemplify this concept in two disease models: Virus-triggered primary hemophagocytic lymphohistiocytosis, an inflammatory syndrome caused by genetically impaired cytolytic functions of T cells, and viral hepatitis, where T cell exhaustion is a major underlying mechanism for impaired effector functions. In both situations, T cells fail to eliminate the source of immune stimulation, which usually serves as an important negative feedback loop curtailing immune reactions. Persistent antigen presentation by antigen-presenting and/or infected cells results in continuous stimulation causing chronic inflammation and immunopathology mediated by residual T cell functions. Hence, immune stimulation or reconstitution rather than immune suppression may be strategies for therapeutic interventions. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peter Aichele
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Ehl
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Toni Cathomen
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Institute for Transfusion Medicine and Gene Therapy, Medical Center - University of Freiburg, Freiburg, Germany
| | - Melanie Boerries
- Institute of Medical Bioinformatics and Systems Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Maike Hofmann
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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24
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Janka GE, Aricò M. Clinical features, diagnosis and therapy of familial haemophagocytic lymphohistiocytosis. Acta Paediatr 2021; 110:2723-2728. [PMID: 33908089 DOI: 10.1111/apa.15889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/04/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023]
Abstract
Familial haemophagocytic lymphohistiocytosis (FHL) is an inherited immune deficiency with defective cytotoxicity of natural killer cells and cytotoxic T lymphocytes. A highly stimulated, but ineffective immune response leads to severe hyperinflammation. Clinical and laboratory features are characteristic, but unspecific; thus awareness of FHL is important for early diagnosis. FHL is rapidly fatal without treatment. Standard-of-care therapy is etoposide and corticosteroids, followed by haematopoietic stem cell transplantation (HSCT). CONCLUSION: FHL has become a curable disease with present treatment. Additional cytokine-directed therapy still has to prove its value. Earlier HSCT and less toxic conditioning regimens will lead to improved cure rates.
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Affiliation(s)
- Gritta E. Janka
- Department of Paediatric Haematology and Oncology University Medical Center Hamburg Germany
| | - Maurizio Aricò
- Strategic Direction Staff, Children's Hospital Giovanni XXIII, Azienda Ospedaliero Universitaria Consorziale Policlinico Bari Italy
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25
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Pereira MAM, da Costa LMM, Nascimento SB, Kang HC, Gabriel AHD. Hemophagocytic lymphohistiocytosis in adults: A key issue in the COVID-19 era. CLINICAL INFECTION IN PRACTICE 2021; 12:100100. [PMID: 34549179 PMCID: PMC8447538 DOI: 10.1016/j.clinpr.2021.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/04/2021] [Accepted: 09/14/2021] [Indexed: 11/04/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by persistent activation of the mononuclear phagocytic system, systemic inflammation, and hypercytokinaemia, which can lead to liver failure, “sepsis-like syndrome” and ultimately, to multiple organ failure and death. These disorders can be divided into primary and secondary (or reactive), the first, also known as familial HLH, is a genetic condition of childhood, which affects the function of TCD8 and NK cells, and usually presents in the first year of life. The secondary HLH affects mainly adults and adolescents and, it's more related to dysregulation of the immune system. In face of the COVID-19 pandemic and several reports of HLH by SARS-CoV-2, it is necessary to discuss the pathophysiology of HLH in adults more clearly. Thus, we present, for the first time, a didactic approach using illustrations and tables, compiling the most recent and relevant information to better understand this entity.
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Affiliation(s)
- Miguel Augusto Martins Pereira
- Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil.,Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro, Brazil
| | | | | | - Hye Chung Kang
- Universidade Federal Fluminense, Departamento de Patologia, Niterói, Rio de Janeiro, Brazil
| | - Adelmo Henrique Daumas Gabriel
- Universidade Federal Fluminense, Departamento de Medicina Clínica, Niterói, Rio de Janeiro, Brazil.,Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
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26
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Meazza Prina M, Martini F, Bracchi F, Di Mauro D, Fargnoli A, Motta M, Giussani C, Gobbin G, Taverna M, D'Alessio A. Hemophagocytic syndrome secondary to SARS-Cov-2 infection: a case report. BMC Infect Dis 2021; 21:811. [PMID: 34388982 PMCID: PMC8361241 DOI: 10.1186/s12879-021-06532-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hemophagocytic syndrome (HPS) is a severe hyperinflammatory disease, whose diagnosis is based on the HLH-2004 criteria. In secondary forms of HLH (sHLH), the primary goal is treating the triggering factors such as COVID-19 (Coronavirus disease 2019). The link between the cytokine storm related to COVID-19 and development of sHLH has already been reported since the onset of pandemic, but little is known about clinical manifestations of HLH which develop after the patient’s recovery from mild symptomatic or asymptomatic Sars-CoV-2 infection. Case presentation We describe the case of a woman diagnosed with sHLH related to previous Sars-CoV-2 infection and successfully treated with steroids, colchicine, etoposide and ruxolitinib. Conclusions Our report suggests that HLH-like syndrome might be secondary to Sars-CoV-2 infection, even if the patient utterly recovered from the mildly symptomatic viral infection. In addition, we underline the treatment with low dose ruxolitinib plus etoposide as a potential choice for Sars-CoV-2 infection related HLH.
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Affiliation(s)
- Marco Meazza Prina
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Francesca Martini
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy.
| | - Federico Bracchi
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Daniela Di Mauro
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Anna Fargnoli
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Marco Motta
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Cristina Giussani
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Giovanni Gobbin
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Monica Taverna
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
| | - Andrea D'Alessio
- Department of Internal Medicine and Onco-Haematology Policlinico S.Marco, GSD University and Research Hospital, Corso Europa 7, 24040, Zingonia, BG, Italy
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High-risk LCH in infants is serially transplantable in a xenograft model but responds durably to targeted therapy. Blood Adv 2021; 4:717-727. [PMID: 32092141 DOI: 10.1182/bloodadvances.2019032367] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 01/22/2020] [Indexed: 01/18/2023] Open
Abstract
Langerhans cell histiocytosis (LCH) is a rare hematologic neoplasm characterized by a clonal proliferation of Langerhans-like cells. Genomic profiling has identified recurrent somatic activating mutations in the mitogen-activated protein kinase pathway, which are targetable by small-molecule inhibitors. However, key questions such as the curative potential of targeted therapy and the cell of origin remain unanswered. In this study, we describe clinical outcomes of a series of pediatric patients with multisystem BRAF V600E-mutant LCH, as well as the results of accompanying murine xenograft experiments. Four infants with LCH (range, 7-11 months at diagnosis) and secondary hemophagocytic lymphohistiocytosis were referred to our institution and subsequently treated with the BRAF V600E-specific inhibitor dabrafenib. All patients achieved complete clinical responses by 8 weeks of therapy, with remissions lasting a median of 36 months (range, 27-42 months). One infant successfully discontinued therapy long-term upon achieving a molecular response by real-time quantitative polymerase chain reaction (RT-qPCR). We further characterized the disease-propagating cell population in a subset of these patients by transplanting whole bone marrow into immunodeficient mice. Xenografted animals exhibited decreased survival with hematologic abnormalities, splenomegaly, and histiocytic infiltrates in the bone marrow resembling human disease. This process could also be secondarily transplanted, resulting in a comparable disease latency with similar histologic findings. These data further support the presence of a disease-initiating cell in the bone marrow compartment. We demonstrate that despite aggressive disease behavior in a xenograft model, these patients can achieve sustained clinical remissions with targeted monotherapy, with a select subset achieving molecular responses by RT-qPCR.
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Fournier B, Latour S. Immunity to EBV as revealed by immunedeficiencies. Curr Opin Immunol 2021; 72:107-115. [PMID: 33989894 DOI: 10.1016/j.coi.2021.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023]
Abstract
Epstein-Barr virus infection is the most common viral latent infection in humans and represents one prototypical model to study immunity to viral infections. In that respect, inborn errors of immunity (IEIs) or primary immunodeficiencies (PIDs) predisposing to severe and chronic EBV infections provide peculiar examples to decipher-specific molecular and cellular components involved in the immune control of EBV-infected cells. Herein, we discuss the recent knowledge and concepts arising from these studies, with a particular focus on 'atypical' EBV infections when EBV enters T, NK and smooth muscle cells, instead of the common 'typical' infection of B cells.
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Affiliation(s)
- Benjamin Fournier
- Laboratory of Lymphocyte Activation and Susceptibility to EBV Infection, INSERM UMR 1163, Imagine Institute, Paris, France; Université de Paris, F75006 Paris, France; Department of Pediatric Immunology, Hematology and Rheumatology, Necker-Enfants Malades, Paris, France
| | - Sylvain Latour
- Laboratory of Lymphocyte Activation and Susceptibility to EBV Infection, INSERM UMR 1163, Imagine Institute, Paris, France; Université de Paris, F75006 Paris, France.
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Yildiz H, Bailly S, Van Den Neste E, Yombi JC. Clinical Management of Relapsed/Refractory Hemophagocytic Lymphohistiocytosis in Adult Patients: A Review of Current Strategies and Emerging Therapies. Ther Clin Risk Manag 2021; 17:293-304. [PMID: 33888986 PMCID: PMC8056168 DOI: 10.2147/tcrm.s195538] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is a severe disorder with high mortality. The aim of this review is to update clinical management of relapsed/refractory HLH in adults, with a focus on current and new therapies. Methods We searched relevant articles in Embase and PUBMED with the MESH term “hemophagocytic lymphohistiocytosis; refractory; relapsing; adult.” Results One hundred eight papers were found; of these, 22 were retained for this review. The treatment of HLH in adult is based on the HLH-94 regimen. The response rate is lower than in pediatric patients, and 20–30% are refractory to this therapy. DEP regimen and allogenic hematopoietic stem cell transplantation (HSCT) are associated with complete response and partial response in 27% and 49.2%, respectively. However, many patients fail to achieve a stable condition before HSCT, and mortality is higher in them. New drugs have been developed, such as emapalumab, ruxolitinib, and alemtuzumab, and they may be used as bridges to the curative HSCT. They are relatively well tolerated and have few or mild side effects. With these agents, the rate of partial response ranges from 14.2% to 100%, while the rate of complete response is highly variable according to study and medication used. The number of patients who achieved HSCT ranged from 44.8% to 77%, with a survival rate of 55.9% to 100%. However, the populations in these studies are mainly composed of mixed-age patients (pediatric and adult patients), and studies including only adult patients are scarce. Conclusion Relapsed or refractory HLH in adult patients is associated with poor outcome, and consolidation with HSCT may be required in some cases. Mortality related to HSCT is mainly due to active HLH disease before HSCT and post HSCT complications. New drugs, such as empalumab, ruxolitinib, and alemtuzumab are interesting since these agents may be used as bridges to HSCT with increases in the numbers of patients proceeding to HSCT and survival rate.
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Affiliation(s)
- Halil Yildiz
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Sarah Bailly
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Eric Van Den Neste
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Jean Cyr Yombi
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
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Taieb G, Kaphan E, Duflos C, Lebrun-Frénay C, Rigau V, Thouvenot E, Duhin-Gand E, Lefaucheur R, Hoang-Xuan K, Coulette S, Ouallet JC, Menjot de Champfleur N, Tranchant C, Picard C, Fusaro M, Sepulveda FE, Labauge P, de Saint Basile G. Hemophagocytic Lymphohistiocytosis Gene Mutations in Adult Patients Presenting With CLIPPERS-Like Syndrome. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/3/e970. [PMID: 33658321 PMCID: PMC7963436 DOI: 10.1212/nxi.0000000000000970] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022]
Abstract
Objective To determine whether adult cases of Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) may be related to familial hemophagocytic lymphohistiocytosis (HLH) causes, we have screened patients with adult-onset CLIPPERS for mutations in primary HLH-associated genes. Methods In our cohort of 36 patients fulfilling the criteria for probable or definite CLIPPERS according to the CLIPPERS-2017 criteria, we conducted a first study on 12 patients who consented to genetic testing. In these 12 patients, systemic HLH criteria were searched, and genetic analysis of 8 genes involved in primary HLH was performed. Results Four definite and 8 probable CLIPPERS were enrolled (n = 12). Mutations involved in HLH were identified in 2 definite and 2 probable CLIPPERS (4/12). Three of them had biallelic PRF1 mutations with reduced perforin expression in natural killer cells. The remaining patient had biallelic UNC13D mutations with cytotoxic lymphocyte impaired degranulation. None of the mutated patients reached the criteria for systemic HLH. During follow-up, 3 of them displayed atypical findings for CLIPPERS, including emergence of systemic non-Hodgkin lymphoma (1/3) and confluent gadolinium-enhancing lesions on brain MRI (3/3). Conclusions In our patients presenting with adult-onset CLIPPERS, one-third have HLH gene mutations. This genetic treatable condition should be searched in patients with CLIPPERS, especially in those presenting with atypical findings.
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Affiliation(s)
- Guillaume Taieb
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France.
| | - Elsa Kaphan
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Claire Duflos
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Christine Lebrun-Frénay
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Valérie Rigau
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Eric Thouvenot
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Emeline Duhin-Gand
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Romain Lefaucheur
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Khe Hoang-Xuan
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Sarah Coulette
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Jean Christophe Ouallet
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Nicolas Menjot de Champfleur
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Christine Tranchant
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Capucine Picard
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Mathieu Fusaro
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Fernando E Sepulveda
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Pierre Labauge
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Geneviève de Saint Basile
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
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31
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Goudouris ES. Immunodeficiencies: non-infectious manifestations. J Pediatr (Rio J) 2021; 97 Suppl 1:S24-S33. [PMID: 33176164 PMCID: PMC9432189 DOI: 10.1016/j.jped.2020.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Classical immunodeficiencies are mainly characterized by infectious conditions. In recent years, manifestations related to allergy, inflammation, autoimmunity, lymphoproliferation, and malignancies related to this group of diseases have been described. The text intends to make an update on the non-infectious manifestations of the primary defects of the immune system. SOURCE OF DATA Searches were carried out in the PubMed database for review articles published in the last five years, in English, French, or Spanish, using the terms "allergy," "inflammation," "autoimmunity," "lymphoproliferation," "cancer," AND "immunodeficiency" or "primary immunodeficiency" or "inborn errors of immunity" NOT "HIV". SYNTHESIS OF DATA Non-infectious manifestations characterize the primary defects in which there is dysregulation of the immune system. The most common manifestations of autoimmunity in this group of diseases are autoimmune cytopenias. Exacerbated inflammatory processes, benign lymphoproliferation, and propensity to malignancy of the lymphoreticular system are related to several diseases in this group. Severe manifestations of atopy or food allergy characterize some immunodeficiencies. Disorders of inborn immunity of the autoinflammatory type are characterized by an aseptic inflammatory process in the absence of autoimmunity, with fever and recurrent manifestations in different organs. CONCLUSIONS Not only infectious conditions should raise the suspicion of immunodeficiencies, but also manifestations of allergy, inflammation, autoimmunity, lymphoproliferation, or cancer, especially if they are recurrent, associated to each other, affecting young patients, or in severe and/or difficult to treat conditions.
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Affiliation(s)
- Ekaterini Simões Goudouris
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Faculdade de Medicina, Departamento de Pediatria, Rio de Janeiro, RJ, Brazil.
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32
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Hong R, Hu Y, Huang H. Biomarkers for Chimeric Antigen Receptor T Cell Therapy in Acute Lymphoblastic Leukemia: Prospects for Personalized Management and Prognostic Prediction. Front Immunol 2021; 12:627764. [PMID: 33717147 PMCID: PMC7947199 DOI: 10.3389/fimmu.2021.627764] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/18/2021] [Indexed: 12/15/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy represents a breakthrough in immunotherapy with the potential of ushering in a new era in cancer treatment. Remarkable therapeutic response and complete remission of this innovative management have been observed in patients with relapse/refractory acute lymphoblastic leukemia. With CAR-T cell therapy becoming widely used both in multicenter clinical trials and as a commercial treatment, therapeutic efficacy monitoring and management of toxicities will be indispensable for ensuring safety and improving overall survival. Biomarkers can act not only as effective indicators reflecting patients' baseline characteristics, CAR-T cell potency, and the immune microenvironment, but can also assess side effects during treatment. In this review, we will elaborate on a series of biomarkers associated with therapeutic response as well as treatment-related toxicities, and present their current condition and latent value with respect to the clinical utility. The combination of biomarker research and CAR-T cell therapy will contribute to establishing a safer and more powerful monitoring system and prolonging the event-free survival of patients.
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Affiliation(s)
- Ruimin Hong
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
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33
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Thomason JL, Obih UM, Koelle DM, Lood C, Hughes AG. An interferon-gamma release assay as a novel biomarker in systemic lupus erythematosus. Rheumatology (Oxford) 2021; 59:3479-3487. [PMID: 32375180 DOI: 10.1093/rheumatology/keaa161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/22/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The mycobacterium tuberculosis (TB) IFN-γ release assay (TB-IGRA) assesses peripheral blood cell release of IFN-γ upon ex vivo exposure to mitogen (IGRA-MT), TB antigen or a negative/nil control (IGRA-NL); IGRA-NL is a measure of spontaneous IFN-γ release (SIR). Here, we investigate the diagnostic associations of elevated SIR and the potential use of IGRA-NL as a novel biomarker in SLE. METHODS We analysed diagnostic code frequencies among 11 823 individuals undergoing TB-IGRA testing between 2010 and 2015 in a large urban US health-care system. To study the relationship between IGRA-NL and SLE, we identified 99 individuals with SLE and TB-IGRA test results then assessed correlations between IGRA-NL, normalized IGRA-NL (the quotient of IGRA-NL/IGRA-MT), disease manifestations and disease activity. RESULTS We identified a discovery cohort of 108 individuals with elevated SIR (>5 S.d. above median) that was significantly enriched for a limited set of diagnoses, including SLE, TB infection, haemophagocytic lymphohistiocytosis and HIV infection. In SLE patients undergoing TB-IGRA testing, normalized IGRA-NL correlated better with disease activity than did anti-dsDNA or complement levels. This relationship appeared to reflect interactions between normalized IGRA-NL and the presence of acute skin disease, hypocomplementemia, fever and thrombocytopenia. CONCLUSION Elevated SIR appears to be associated with a limited number of disease processes, including SLE. The diagnostic utility of SIR remains to be determined. IFN-γ activation, as measured by the TB-IGRA test, may offer a readily available tool for assessing disease activity in patients with SLE.
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Affiliation(s)
- Jenna L Thomason
- Department of Medicine, Division of Rheumatology, University of Washington
| | - Uchechukwu M Obih
- Department of Medicine, Division of Rheumatology, University of Washington.,Department of Rheumatology, Swedish Medical Center
| | - David M Koelle
- Department of Medicine, Division of Infectious Diseases, University of Washington.,Department of Laboratory Medicine, University of Washington.,Department of Global Health, University of Washington.,Fred Hutchinson Cancer Research Center.,Benaroya Research Institute, Seattle, WA, USA
| | - Christian Lood
- Department of Medicine, Division of Rheumatology, University of Washington
| | - And Grant Hughes
- Department of Medicine, Division of Rheumatology, University of Washington
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Diamantidis MD, Palioura A, Ioannou M, Tsangalas E, Karakousis K. Hemophagocytic Lymphohistiocytosis as a Manifestation of Underlying Visceral Leishmaniasis. Cureus 2020; 12:e11911. [PMID: 33304709 PMCID: PMC7719485 DOI: 10.7759/cureus.11911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or hemophagocytic syndrome (HS) is a severe syndrome involving an extreme participation of the immune system, resulting in a cascade of cytokines, hyperinflammation and extensive hemophagocytosis in the bone marrow (BM) and affecting the peripheral blood (PB) lineages. Fever, splenomegaly, hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia are often encountered in this disease. The syndrome can be seen in all ages and it is either primary due to genetic defects or secondary because of malignancies, immune deficiencies, rheumatic diseases, and infections. Bacteria, viruses, protozoa, and fungi are often implicated. Visceral leishmaniasis (VL) is among the infectious causes of HLH. We describe a patient with a successful treatment of HLH after the initiation of liposomal amphotericin B, due to VL, even though there was a delay in diagnosing the leishmaniasis. The exact precipitating pathophysiological events triggering HLH remain unknown and provide their clear impact for future research. An instructive, critical review of the literature related to the presented case is provided. Distinguishing secondary HS from primary HS is essential for the application of suitable treatment. Improper use of corticosteroids could cover up an underlying possible malignancy or infection and delay the initiation of the etiologic therapeutic strategy.
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Affiliation(s)
- Michael D Diamantidis
- Hematology, First Department of Internal Medicine, Thalassemia and Sickle Cell Disease Unit, General Hospital of Larissa, Larissa, GRC
| | - Andromachi Palioura
- Internal Medicine, First Department of Internal Medicine, General Hospital of Larissa, Larissa, GRC
| | - Maria Ioannou
- Pathology, Haemopathology, University Hospital of Larissa, University of Thessaly, Larissa, GRC
| | - Evangelos Tsangalas
- Hematology, First Department of Internal Medicine, Thalassemia and Sickle Cell Disease Unit, General Hospital of Larissa, Larissa, GRC
| | - Konstantinos Karakousis
- Internal Medicine, First Department of Internal Medicine, General Hospital of Larissa, Larissa, GRC
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Merli P, Algeri M, Gaspari S, Locatelli F. Novel Therapeutic Approaches to Familial HLH (Emapalumab in FHL). Front Immunol 2020; 11:608492. [PMID: 33424859 PMCID: PMC7793976 DOI: 10.3389/fimmu.2020.608492] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 10/30/2020] [Indexed: 12/18/2022] Open
Abstract
Primary Hemophagocytic lymphohistiocytosis (pHLH) is a rare, life-threatening, hyperinflammatory disorder, characterized by uncontrolled activation of the immune system. Mutations affecting several genes coding for proteins involved in the cytotoxicity machinery of both natural killer (NK) and T cells have been found to be responsible for the development of pHLH. So far, front-line treatment, established on the results of large international trials, is based on the use of glucocorticoids, etoposide ± cyclosporine, followed by allogeneic hematopoietic stem cell transplantation (HSCT), the sole curative treatment for the genetic forms of the disease. However, despite major efforts to improve the outcome of pHLH, many patients still experience unfavorable outcomes, as well as severe toxicities; moreover, treatment-refractory or relapsing disease is a major challenge for pediatricians/hematologists. In this article, we review the epidemiology, etiology and pathophysiology of pHLH, with a particular focus on different cytokines at the origin of the disease. The central role of interferon-γ (IFNγ) in the development and maintenance of hyperinflammation is analyzed. The value of emapalumab, a novel IFNγ-neutralizing monoclonal antibody is discussed. Available data support the use of emapalumab for treatment of pHLH patients with refractory, recurrent or progressive disease, or intolerance to conventional therapy, recently, leading to FDA approval of the drug for these indications. Additional data are needed to define the role of emapalumab in front-line treatment or in combination with other drugs.
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Affiliation(s)
- Pietro Merli
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Mattia Algeri
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stefania Gaspari
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy.,Department of Maternal, Infantile, and Urological Sciences, Sapienza, University of Rome, Rome, Italy
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36
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Pediatric hemophagocytic lymphohistiocytosis. Blood 2020; 135:1332-1343. [PMID: 32107531 DOI: 10.1182/blood.2019000936] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/27/2020] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome describing patients with severe systemic hyperinflammation. Characteristic features include unremitting fever, cytopenias, hepatosplenomegaly, and elevation of typical HLH biomarkers. Patients can develop hepatitis, coagulopathy, liver failure, central nervous system involvement, multiorgan failure, and other manifestations. The syndrome has a high mortality rate. More and more, it is recognized that while HLH can be appropriately used as a broad summary diagnosis, many pediatric patients actually suffer from an expanding spectrum of genetic diseases that can be complicated by the syndrome of HLH. Classic genetic diseases in which HLH is a typical and common manifestation include pathogenic changes in familial HLH genes (PRF1, UNC13D, STXBP2, and STX11), several granule/pigment abnormality genes (RAB27A, LYST, and AP3B1), X-linked lymphoproliferative disease genes (SH2D1A and XIAP), and others such as NLRC4, CDC42, and the Epstein-Barr virus susceptibility diseases. There are many other genetic diseases in which HLH is an infrequent complication of the disorder as opposed to a prominent manifestation of the disease caused directly by the genetic defect, including other primary immune deficiencies and inborn errors of metabolism. HLH can also occur in patients with underlying rheumatologic or autoinflammatory disorders and is usually designated macrophage activation syndrome in those settings. Additionally, HLH can develop in patients during infections or malignancies without a known (or as-yet-identified) genetic predisposition. This article will attempt to summarize current concepts in the pediatric HLH field as well as offer a practical diagnostic and treatment overview.
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Cabler SS, Hogan PG, Fritz SA, Bednarski JJ, Hunstad DA. Incidence and treatment of hemophagocytic lymphohistiocytosis in hospitalized children with Ehrlichia infection. Pediatr Blood Cancer 2020; 67:e28436. [PMID: 32706439 DOI: 10.1002/pbc.28436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/23/2022]
Abstract
We report a large cohort of pediatric patients with human monocytic ehrlichiosis (HME), enabling an estimated incidence of secondary hemophagocytic lymphohistiocytosis (HLH) in hospitalized children with HME. Among 49 children with PCR-confirmed Ehrlichia infection, 8 (16%) met current criteria for HLH. Those with HLH had more significant hematologic abnormalities and longer durations from symptom onset to admission and definitive anti-infective therapy. Among these eight, three received chemotherapy plus doxycycline, one of whom died; the other five were treated with doxycycline without chemotherapy, and all survived without HLH recurrence. Our findings demonstrate that antimicrobial therapy alone can successfully resolve Ehrlichia-associated HLH.
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Affiliation(s)
- Stephanie S Cabler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick G Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie A Fritz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey J Bednarski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - David A Hunstad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
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[Clinical study of haploidentical hematopoietic stem cell transplantation on 15 cases of adult-onset primary hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:511-516. [PMID: 32654467 PMCID: PMC7378280 DOI: 10.3760/cma.j.issn.0253-2727.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: This study was designed to evaluate the efficacy of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) for adult-onset primary hemophagocytic lymphohistiocytosis (HLH) . Method: A retrospective study was carried out to analyze the clinical data of 15 adult patients with primary HLH who received haplo-HSCT from January 2013 to October 2019 in Beijing Friendship Hospital, Capital Medical University, Beijing, China. Results: Among the 15 patients included in the study, ten were males and five were females, with a median age of 21 years old (18-52) . Eight of the patients had familial hemophagocytic lymphohistiocytosis type 2 (FHL-2) , four had FHL-3, one had Griscelli syndrome type 2 (GS-2) , one had X-linked lymphoproliferative disease type 1 (XLP-1) , and the other had XLP-2. The median time from HLH diagnosis to transplantation was 7 months (2-46 months) . Seven patients were treated with Bu/Cy condition regimen prior to transplantation. Meanwhile, the other eight cases were treated with TBI/Cy. The median concentration of mononuclear cell (MNC) infusion was 12.6 (9.2-20.3) ×10(8)/kg and CD34(+) cells was 4.91 (2.51-8.37) ×10(6)/kg. The median time of leukocyte engraftment was on day 13 following transplantation (10-23 days) , and the platelet engraftment was on day 12 (9-36) . Graft failure (GF) finally occurred in two patients (one primary GF and one secondary GF) . The cumulative incidence of acute graft-versus-host-disease (GVHD) grades 2 to 4 was 71.4% (10/14) and chronic GVHD was 30.8% (4/13) , respectively. The five-year overall survival (OS) for all 15 cases of primary HLH was 65.5% (95% CI, 34.9%-73.3%) and the transplant-related mortality (TRM) was 26.7% (4/15) . The five-year OS was 87.5% (95% CI, 38.7%-66.3%) in eight patients who received haplo-HSCT subsequent to initial therapy and 42.9% (95% CI, 8.5%-65.2%) in patients seven patients who needed salvage therapy prior to haplo-HSCT (χ(2)=2.387, P=0.122) . The five-year OS was 85.7% (95% CI, 50.4%-89.8%) in eight patients who achieved complete response before haplo-HSCT and 42.9% (95% CI, 6.4%-53.0%) in seven patients with partial response (χ(2)=3.185, P=0.074) . Conclusion: The results indicated that haplo-HSCT is a promising method for the treatment of primary HLH in adults.
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Perricone C, Bartoloni E, Bursi R, Cafaro G, Guidelli GM, Shoenfeld Y, Gerli R. COVID-19 as part of the hyperferritinemic syndromes: the role of iron depletion therapy. Immunol Res 2020; 68:213-224. [PMID: 32681497 PMCID: PMC7366458 DOI: 10.1007/s12026-020-09145-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SARS-CoV-2 infection is characterized by a protean clinical picture that can range from asymptomatic patients to life-threatening conditions. Severe COVID-19 patients often display a severe pulmonary involvement and develop neutrophilia, lymphopenia, and strikingly elevated levels of IL-6. There is an over-exuberant cytokine release with hyperferritinemia leading to the idea that COVID-19 is part of the hyperferritinemic syndrome spectrum. Indeed, very high levels of ferritin can occur in other diseases including hemophagocytic lymphohistiocytosis, macrophage activation syndrome, adult-onset Still's disease, catastrophic antiphospholipid syndrome and septic shock. Numerous studies have demonstrated the immunomodulatory effects of ferritin and its association with mortality and sustained inflammatory process. High levels of free iron are harmful in tissues, especially through the redox damage that can lead to fibrosis. Iron chelation represents a pillar in the treatment of iron overload. In addition, it was proven to have an anti-viral and anti-fibrotic activity. Herein, we analyse the pathogenic role of ferritin and iron during SARS-CoV-2 infection and propose iron depletion therapy as a novel therapeutic approach in the COVID-19 pandemic.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, 5265601, Tel-Hashomer, Israel
- The Mosaic of Autoimmunity Project, Saint Petersburg University, Saint Petersburg, Russia
- Ministry of Health of the Russian Federation, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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40
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but severe form of immune dysregulation often presenting as unremitting fever, cytopenia, hepatosplenomegaly, coagulopathy, and elevation of typical HLH biomarkers. HLH is universally fatal, if left untreated. The HLH-2004 criteria are widely used to diagnose this condition, but there is growing concerns across different settings that its application may result in undertreatment of certain patients. There is an expanding spectrum of genetic conditions that can be complicated by HLH. This review summarizes the current concepts in HLH, the lessons learned from the past, and provide an overview of the latest diagnostic and treatment modalities.
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41
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Are there new targets for juvenile idiopathic arthritis? Semin Arthritis Rheum 2020; 49:S11-S13. [PMID: 31779842 DOI: 10.1016/j.semarthrit.2019.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/25/2019] [Indexed: 01/03/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is not a disease but an umbrella term that gather all forms of chronic arthritis of unknown origin and with onset in childhood. Some of these disorders appear to be the childhood equivalent of adult diseases and share therefore the same therapeutic targets. A form characterized by early onset and antinuclear antibody positivity seems to be specific for children but further evidence is needed. Systemic JIA (sJIA), although equivalent to adult onset Still disease is much more frequent in childhood. Novel potential targets for sJIA as well as for macrophage activation syndrome, its more severe complication, have therefore been investigated mainly in children.
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42
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Gather R, Aichele P, Goos N, Rohr J, Pircher H, Kögl T, Zeiser R, Hengel H, Schmitt-Gräff A, Weaver C, Ehl S. Trigger-dependent differences determine therapeutic outcome in murine primary hemophagocytic lymphohistiocytosis. Eur J Immunol 2020; 50:1770-1782. [PMID: 32419134 DOI: 10.1002/eji.201948123] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/29/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is a hyperinflammatory syndrome affecting patients with genetic cytotoxicity defects. Perforin-deficient (PKO) mice recapitulate the full clinical picture of FHL after infection with lymphocytic choriomeningitis virus (LCMV). Hyperactivated CD8+ T cells and IFN-γ have been identified as the key drivers of FHL and represent targets for therapeutic interventions. However, the response of patients is variable. This could be due to trigger-dependent differences in pathogenesis, which is difficult to address in FHL patients, since the trigger frequently escapes detection. We established an alternative FHL model using intravenous infection of PKO mice with murine CMV (MCMV)Smith . PKO mice developed acute FHL after both infections and fulfilled HLH diagnostic criteria accompanied by excessive IFN-γ production by disease-inducing T cells, that enrich in the BM. However, direct comparison of the two infection models disclosed trigger-dependence of FHL progression and revealed a higher contribution of CD4 T cells and NK cells to IFN-γ production after MCMV infection. Importantly, therapeutic intervention by IFN-γ neutralization or CD8+ T-cell depletion had less benefit in MCMV-triggered FHL compared to LCMV-triggered FHL, likely due to MCMV-induced cytopathology. Thus, the context of the specific triggering viral infection can impact the success of targeted immunotherapeutic HLH control.
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Affiliation(s)
- Ruth Gather
- Center for Chronic Immunodeficiency (CCI), Faculty of Medicine, Institute for Immunodeficiency, Medical Center, University of Freiburg, Germany.,Faculty of Biology, University of Freiburg, Germany
| | - Peter Aichele
- Faculty of Medicine, Institute of Immunology, Medical Center, University of Freiburg, Germany
| | - Nadja Goos
- Center for Chronic Immunodeficiency (CCI), Faculty of Medicine, Institute for Immunodeficiency, Medical Center, University of Freiburg, Germany
| | - Jan Rohr
- Center for Chronic Immunodeficiency (CCI), Faculty of Medicine, Institute for Immunodeficiency, Medical Center, University of Freiburg, Germany.,Center for Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center, University of Freiburg, Germany
| | - Hanspeter Pircher
- Faculty of Medicine, Institute of Immunology, Medical Center, University of Freiburg, Germany
| | - Tamara Kögl
- Faculty of Medicine, Institute of Immunology, Medical Center, University of Freiburg, Germany
| | - Robert Zeiser
- Department of Hematology and Oncology, Medical Center, University of Freiburg, Germany
| | - Hartmut Hengel
- Faculty of Medicine, Institute of Virology, Medical Center, University of Freiburg, Germany
| | - Annette Schmitt-Gräff
- Department of General Pathology, Faculty of Medicine, Institute of Pathology, Medical Center, University of Freiburg, Germany
| | - Casey Weaver
- Department of Immunology, School of Medicine, University of Alabama, Birmingham, AL, USA
| | - Stephan Ehl
- Center for Chronic Immunodeficiency (CCI), Faculty of Medicine, Institute for Immunodeficiency, Medical Center, University of Freiburg, Germany
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43
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Eldem İ, Al-Rahawan MM, Levent F. How to Treat Cytomegalovirus-induced Hemophagocytic Lymphohistiocytosis in a Child With Leukemia. J Pediatr Hematol Oncol 2020; 42:313-315. [PMID: 31306340 DOI: 10.1097/mph.0000000000001547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by a hyperinflammatory state due to an aberrant activation of the immune cells. It can be familial or secondary to malignancy, autoimmune or metabolic diseases. Most HLH cases are triggered by infection. Histiocyte society suggested HLH-2004 protocol for diagnosis and treatment of both forms. Here, we present a three-year-old girl with B-cell acute lymphoblastic leukemia who developed HLH secondary to cytomegalovirus infection during maintenance therapy. She was successfully treated without needing full HLH protocol therapy. We discuss modified therapy for this specific group of HLH, summarizing 5 other similar cases in the literature.
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Affiliation(s)
| | | | - Fatma Levent
- Pediatrics, Division of Infectious Disease, Texas Tech University Health Sciences Center, Lubbock, TX
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Latour S, Fischer A. Signaling pathways involved in the T-cell-mediated immunity against Epstein-Barr virus: Lessons from genetic diseases. Immunol Rev 2020; 291:174-189. [PMID: 31402499 DOI: 10.1111/imr.12791] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 12/13/2022]
Abstract
Primary immunodeficiencies (PIDs) provide researchers with unique models to understand in vivo immune responses in general and immunity to infections in particular. In humans, impaired immune control of Epstein-Barr virus (EBV) infection is associated with the occurrence of several different immunopathologic conditions; these include non-malignant and malignant B-cell lymphoproliferative disorders, hemophagocytic lymphohistiocytosis (HLH), a severe inflammatory condition, and a chronic acute EBV infection of T cells. Studies of PIDs associated with a predisposition to develop severe, chronic EBV infections have led to the identification of key components of immunity to EBV - notably the central role of T-cell expansion and its regulation in the pathophysiology of EBV-associated diseases. On one hand, the defective expansion of EBV-specific CD8 T cells results from mutations in genes involved in T-cell activation (such as RASGRP1, MAGT1, and ITK), DNA metabolism (CTPS1) or co-stimulatory pathways (CD70, CD27, and TNFSFR9 (also known as CD137/4-1BB)) leads to impaired elimination of proliferating EBV-infected B cells and the occurrence of lymphoma. On the other hand, protracted T-cell expansion and activation after the defective killing of EBV-infected B cells is caused by genetic defects in the components of the lytic granule exocytosis pathway or in the small adapter protein SH2D1A (also known as SAP), a key activator of T- and NK cell-cytotoxicity. In this setting, the persistence of EBV-infected cells results in HLH, a condition characterized by unleashed T-cell and macrophage activation. Moreover, genetic defects causing selective vulnerability to EBV infection have highlighted the role of co-receptor molecules (CD27, CD137, and SLAM-R) selectively involved in immune responses against infected B cells via specific T-B cell interactions.
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Affiliation(s)
- Sylvain Latour
- Laboratory of Lymphocyte Activation and Susceptibility to EBV infection, Inserm UMR 1163, Paris, France.,University Paris Descartes Sorbonne Paris Cité, Imagine Institut, Paris, France
| | - Alain Fischer
- University Paris Descartes Sorbonne Paris Cité, Imagine Institut, Paris, France.,Department of Pediatric Immunology, Hematology and Rheumatology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Collège de France, Paris, France.,Inserm UMR 1163, Paris, France
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45
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Hemophagocytic lymphohistiocytosis in adults: collaborative analysis of 137 cases of a nationwide German registry. J Cancer Res Clin Oncol 2020; 146:1065-1077. [PMID: 32076823 PMCID: PMC7085479 DOI: 10.1007/s00432-020-03139-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/29/2020] [Indexed: 01/05/2023]
Abstract
Purpose Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome emerging from a deregulated immune response due to various triggers. In adults, systematic data are sparse, which is why recommendations on diagnosis and management have been adopted from pediatric guidelines. A nationwide clinical registry with associated consulting service as collaborative initiative of HLH-specialized pediatricians and hematologists was initiated to better characterize HLH in adults. Methods Patients with proven or suspected HLH were registered by 44 institutions. Both HLH-2004 diagnostic criteria and the HScore (www.saintantoine.aphp.fr/score/) were used to confirm HLH diagnosis. Data referring to underlying disease, treatment, outcome, clinical presentation and laboratory findings were recorded. Results The study included 137 patients and provides the first systematic data on adult HLH in Germany. Median age was 50 years with a wide range (17–87 years), 87 patients (63.5%) were male. Most common triggering diseases were infections in 61 patients (44.5%) and malignancies in 48 patients (35%). Virtually all patients had elevated ferritin concentrations, and 74% had peak concentrations greater than 10,000 µg/l. At time of analysis, 67 of 131 patients (51%) had died. Patients with malignancy-associated HLH had the shortest median survival (160 days), however no statistically significant difference between subgroups was observed (p = 0.077). Platelets under 20*109/l and low albumin concentrations (< 20 g/l) were associated with poor overall and 30-day survival. Conclusion Close multidisciplinary case consultation and cooperation is mandatory when treating adult HLH patients. Early contact with reference centers is recommended, especially in relapsing or refractory disease. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-020-03139-4.
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46
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Sandler RD, Carter S, Kaur H, Francis S, Tattersall RS, Snowden JA. Haemophagocytic lymphohistiocytosis (HLH) following allogeneic haematopoietic stem cell transplantation (HSCT)-time to reappraise with modern diagnostic and treatment strategies? Bone Marrow Transplant 2020; 55:307-316. [PMID: 31455895 PMCID: PMC6995779 DOI: 10.1038/s41409-019-0637-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/28/2019] [Accepted: 06/07/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Robert David Sandler
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.
| | - Stuart Carter
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Harpreet Kaur
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Sebastian Francis
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Rachel Scarlett Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - John Andrew Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
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47
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Lam MT, Coppola S, Krumbach OHF, Prencipe G, Insalaco A, Cifaldi C, Brigida I, Zara E, Scala S, Di Cesare S, Martinelli S, Di Rocco M, Pascarella A, Niceta M, Pantaleoni F, Ciolfi A, Netter P, Carisey AF, Diehl M, Akbarzadeh M, Conti F, Merli P, Pastore A, Levi Mortera S, Camerini S, Farina L, Buchholzer M, Pannone L, Cao TN, Coban-Akdemir ZH, Jhangiani SN, Muzny DM, Gibbs RA, Basso-Ricci L, Chiriaco M, Dvorsky R, Putignani L, Carsetti R, Janning P, Stray-Pedersen A, Erichsen HC, Horne A, Bryceson YT, Torralba-Raga L, Ramme K, Rosti V, Bracaglia C, Messia V, Palma P, Finocchi A, Locatelli F, Chinn IK, Lupski JR, Mace EM, Cancrini C, Aiuti A, Ahmadian MR, Orange JS, De Benedetti F, Tartaglia M. A novel disorder involving dyshematopoiesis, inflammation, and HLH due to aberrant CDC42 function. THE JOURNAL OF EXPERIMENTAL MEDICINE 2019. [PMID: 31601675 DOI: 10.1084/jem.20190147)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is characterized by immune dysregulation due to inadequate restraint of overactivated immune cells and is associated with a variable clinical spectrum having overlap with more common pathophysiologies. HLH is difficult to diagnose and can be part of inflammatory syndromes. Here, we identify a novel hematological/autoinflammatory condition (NOCARH syndrome) in four unrelated patients with superimposable features, including neonatal-onset cytopenia with dyshematopoiesis, autoinflammation, rash, and HLH. Patients shared the same de novo CDC42 mutation (Chr1:22417990C>T, p.R186C) and altered hematopoietic compartment, immune dysregulation, and inflammation. CDC42 mutations had been associated with syndromic neurodevelopmental disorders. In vitro and in vivo assays documented unique effects of p.R186C on CDC42 localization and function, correlating with the distinctiveness of the trait. Emapalumab was critical to the survival of one patient, who underwent successful bone marrow transplantation. Early recognition of the disorder and establishment of treatment followed by bone marrow transplant are important to survival.
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Affiliation(s)
- Michael T Lam
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY.,Medical Scientist Training Program and Translational Biology and Molecular Medicine Graduate Program, Baylor College of Medicine, Houston, TX
| | - Simona Coppola
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Oliver H F Krumbach
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Giusi Prencipe
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonella Insalaco
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Cristina Cifaldi
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Immacolata Brigida
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Erika Zara
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Serena Scala
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Di Cesare
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Simone Martinelli
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Martina Di Rocco
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy.,Department of Cellular Biotechnology and Haematology, Sapienza University of Rome, Rome, Italy
| | - Antonia Pascarella
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Marcello Niceta
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Francesca Pantaleoni
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Ciolfi
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Petra Netter
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Alexandre F Carisey
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY
| | - Michael Diehl
- Department of Bioengineering, Rice University, Houston, TX
| | - Mohammad Akbarzadeh
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Francesca Conti
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Anna Pastore
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Stefano Levi Mortera
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Serena Camerini
- Core Facilities, Italian National Institute of Health, Rome, Italy
| | - Luciapia Farina
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy.,Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Marcel Buchholzer
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Luca Pannone
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy.,Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Tram N Cao
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Zeynep H Coban-Akdemir
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Shalini N Jhangiani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.,Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Donna M Muzny
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.,Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Richard A Gibbs
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.,Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Luca Basso-Ricci
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiriaco
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Radovan Dvorsky
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Lorenza Putignani
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Rita Carsetti
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Petra Janning
- Department of Chemical Biology, Max-Planck Institute of Molecular Physiology, Dortmund, Germany
| | - Asbjorg Stray-Pedersen
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX.,Norwegian National Unit for Newborn Screening, Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - AnnaCarin Horne
- Pediatric Rheumatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Yenan T Bryceson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Broegelmann Research Laboratory, Institute of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Lamberto Torralba-Raga
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Kim Ramme
- Pediatric Hematology, Immunology and HCT Section, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Vittorio Rosti
- Center for Myelofibrosis, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Claudia Bracaglia
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Virginia Messia
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Paolo Palma
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Finocchi
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Pediatrics, Sapienza University of Rome, Italy
| | - Ivan K Chinn
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Division of Pediatric Immunology, Allergy, Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - James R Lupski
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Baylor-Hopkins Center for Mendelian Genomics, Houston, TX.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.,Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Emily M Mace
- Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY
| | - Caterina Cancrini
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy.,Pediatric Immunohematology, San Raffaele Scientific Institute, Milan, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Mohammad R Ahmadian
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Jordan S Orange
- Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY .,Medical Scientist Training Program and Translational Biology and Molecular Medicine Graduate Program, Baylor College of Medicine, Houston, TX
| | - Fabrizio De Benedetti
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Lam MT, Coppola S, Krumbach OHF, Prencipe G, Insalaco A, Cifaldi C, Brigida I, Zara E, Scala S, Di Cesare S, Martinelli S, Di Rocco M, Pascarella A, Niceta M, Pantaleoni F, Ciolfi A, Netter P, Carisey AF, Diehl M, Akbarzadeh M, Conti F, Merli P, Pastore A, Levi Mortera S, Camerini S, Farina L, Buchholzer M, Pannone L, Cao TN, Coban-Akdemir ZH, Jhangiani SN, Muzny DM, Gibbs RA, Basso-Ricci L, Chiriaco M, Dvorsky R, Putignani L, Carsetti R, Janning P, Stray-Pedersen A, Erichsen HC, Horne A, Bryceson YT, Torralba-Raga L, Ramme K, Rosti V, Bracaglia C, Messia V, Palma P, Finocchi A, Locatelli F, Chinn IK, Lupski JR, Mace EM, Cancrini C, Aiuti A, Ahmadian MR, Orange JS, De Benedetti F, Tartaglia M. A novel disorder involving dyshematopoiesis, inflammation, and HLH due to aberrant CDC42 function. J Exp Med 2019; 216:2778-2799. [PMID: 31601675 PMCID: PMC6888978 DOI: 10.1084/jem.20190147] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/19/2019] [Accepted: 08/06/2019] [Indexed: 12/27/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is characterized by immune dysregulation due to inadequate restraint of overactivated immune cells and is associated with a variable clinical spectrum having overlap with more common pathophysiologies. HLH is difficult to diagnose and can be part of inflammatory syndromes. Here, we identify a novel hematological/autoinflammatory condition (NOCARH syndrome) in four unrelated patients with superimposable features, including neonatal-onset cytopenia with dyshematopoiesis, autoinflammation, rash, and HLH. Patients shared the same de novo CDC42 mutation (Chr1:22417990C>T, p.R186C) and altered hematopoietic compartment, immune dysregulation, and inflammation. CDC42 mutations had been associated with syndromic neurodevelopmental disorders. In vitro and in vivo assays documented unique effects of p.R186C on CDC42 localization and function, correlating with the distinctiveness of the trait. Emapalumab was critical to the survival of one patient, who underwent successful bone marrow transplantation. Early recognition of the disorder and establishment of treatment followed by bone marrow transplant are important to survival.
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Affiliation(s)
- Michael T Lam
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY
- Medical Scientist Training Program and Translational Biology and Molecular Medicine Graduate Program, Baylor College of Medicine, Houston, TX
| | - Simona Coppola
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Oliver H F Krumbach
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Giusi Prencipe
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonella Insalaco
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Cristina Cifaldi
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Immacolata Brigida
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Erika Zara
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Serena Scala
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Di Cesare
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Simone Martinelli
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Martina Di Rocco
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
- Department of Cellular Biotechnology and Haematology, Sapienza University of Rome, Rome, Italy
| | - Antonia Pascarella
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Marcello Niceta
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Francesca Pantaleoni
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Ciolfi
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Petra Netter
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Alexandre F Carisey
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY
| | - Michael Diehl
- Department of Bioengineering, Rice University, Houston, TX
| | - Mohammad Akbarzadeh
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Francesca Conti
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Anna Pastore
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Stefano Levi Mortera
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Serena Camerini
- Core Facilities, Italian National Institute of Health, Rome, Italy
| | - Luciapia Farina
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Marcel Buchholzer
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Luca Pannone
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Tram N Cao
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Zeynep H Coban-Akdemir
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Shalini N Jhangiani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
- Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Donna M Muzny
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
- Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Richard A Gibbs
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
- Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Luca Basso-Ricci
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiriaco
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Radovan Dvorsky
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Lorenza Putignani
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Rita Carsetti
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Petra Janning
- Department of Chemical Biology, Max-Planck Institute of Molecular Physiology, Dortmund, Germany
| | - Asbjorg Stray-Pedersen
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX
- Norwegian National Unit for Newborn Screening, Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - AnnaCarin Horne
- Pediatric Rheumatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Yenan T Bryceson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Broegelmann Research Laboratory, Institute of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Lamberto Torralba-Raga
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Kim Ramme
- Pediatric Hematology, Immunology and HCT Section, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Vittorio Rosti
- Center for Myelofibrosis, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Claudia Bracaglia
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Virginia Messia
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Paolo Palma
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Finocchi
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Department of Pediatrics, Sapienza University of Rome, Italy
| | - Ivan K Chinn
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Division of Pediatric Immunology, Allergy, Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - James R Lupski
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Baylor-Hopkins Center for Mendelian Genomics, Houston, TX
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
- Human Genome Sequencing Center of Baylor College of Medicine, Houston, TX
| | - Emily M Mace
- Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY
| | - Caterina Cancrini
- Academic Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Pediatric Immunohematology, San Raffaele Scientific Institute, Milan, Italy
- Vita Salute San Raffaele University, Milan, Italy
| | - Mohammad R Ahmadian
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Jordan S Orange
- Department of Pediatrics, Columbia University, Irving Medical Center, New York, NY
- Medical Scientist Training Program and Translational Biology and Molecular Medicine Graduate Program, Baylor College of Medicine, Houston, TX
| | - Fabrizio De Benedetti
- Immunology Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Abstract
Natural killer (NK) cell deficiency (NKD) is a subset of primary immunodeficiency disorders (PID) in which an abnormality of NK cells represents a major immunological defect resulting in the patient’s clinical immunodeficiency. This is distinct from a much larger group of PIDs that include an NK cell abnormality as a minor component of the immunodeficiency. Patients with NKD most frequently have atypical consequences of herpesviral infections. There are now 6 genes that have been ascribed to causing NKD, some exclusively and others that also cause other known immunodeficiencies. This list has grown in recent years and as such the mechanistic and molecular clarity around what defines an NKD is an emerging and important field of research. Continued increased clarity will allow for more rational approaches to the patients themselves from a therapeutic standpoint. Having evaluated numerous individuals for NKD, I share my perspective on approaching the diagnosis and managing these patients.
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Affiliation(s)
- Jordan S Orange
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physicians and Surgeons, 622 W 168th St., New York, NY, 10032, USA.
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Rotoli BM, Barilli A, Visigalli R, Ferrari F, Dall'Asta V. y+LAT1 and y+LAT2 contribution to arginine uptake in different human cell models: Implications in the pathophysiology of Lysinuric Protein Intolerance. J Cell Mol Med 2019; 24:921-929. [PMID: 31705628 PMCID: PMC6933409 DOI: 10.1111/jcmm.14801] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/04/2019] [Accepted: 09/15/2019] [Indexed: 12/27/2022] Open
Abstract
y+LAT1 (encoded by SLC7A7), together with y+LAT2 (encoded by SLC7A6), is the alternative light subunits composing the heterodimeric transport system y+L for cationic and neutral amino acids. SLC7A7 mutations cause lysinuric protein intolerance (LPI), an inherited multisystem disease characterized by low plasma levels of arginine and lysine, protein-rich food intolerance, failure to thrive, hepatosplenomegaly, osteoporosis, lung involvement, kidney failure, haematologic and immunological disorders. The reason for the heterogeneity of LPI symptoms is thus far only poorly understood. Here, we aimed to quantitatively compare the expression of SLC7A7 and SLC7A6 among different human cell types and evaluate y+LAT1 and y+LAT2 contribution to arginine transport. We demonstrate that system y+L-mediated arginine transport is mainly accounted for by y+LAT1 in monocyte-derived macrophages (MDM) and y+LAT2 in fibroblasts. The kinetic analysis of arginine transport indicates that y+LAT1 and y+LAT2 share a comparable affinity for the substrate. Differences have been highlighted in the expression of SLC7A6 and SLC7A7 mRNA among different cell models: while SLC7A6 is almost equally expressed, SLC7A7 is particularly abundant in MDM, intestinal Caco-2 cells and human renal proximal tubular epithelial cells (HRPTEpC). The characterization of arginine uptake demonstrates that system y+L is operative in renal cells and in Caco-2 where, at the basolateral side, it mediates arginine efflux in exchange with leucine plus sodium. These findings explain the defective absorption/reabsorption of arginine in LPI. Moreover, y+LAT1 is the prevailing transporter in MDM sustaining a pivotal role in the pathogenesis of immunological complications associated with the disease.
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Affiliation(s)
- Bianca Maria Rotoli
- Laboratory of General Pathology, Department of Medicine and Surgery (DiMec), University of Parma, Parma, Italy
| | - Amelia Barilli
- Laboratory of General Pathology, Department of Medicine and Surgery (DiMec), University of Parma, Parma, Italy
| | - Rossana Visigalli
- Laboratory of General Pathology, Department of Medicine and Surgery (DiMec), University of Parma, Parma, Italy
| | - Francesca Ferrari
- Laboratory of General Pathology, Department of Medicine and Surgery (DiMec), University of Parma, Parma, Italy
| | - Valeria Dall'Asta
- Laboratory of General Pathology, Department of Medicine and Surgery (DiMec), University of Parma, Parma, Italy
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