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Chandrakasan S, Jordan MB, Baker A, Behrens EM, Bhatla D, Chien M, Eckstein OS, Henry MM, Hermiston ML, Hinson AP, Leiding JW, Oladapo A, Patel SA, Pednekar P, Ray AK, Dávila Saldaña B, Sarangi SN, Walkovich KJ, Yee JD, Zoref-Lorenz A, Allen CE. Real-world treatment patterns and outcomes in patients with primary hemophagocytic lymphohistiocytosis treated with emapalumab. Blood Adv 2024; 8:2248-2258. [PMID: 38429096 PMCID: PMC11117018 DOI: 10.1182/bloodadvances.2023012217] [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: 11/27/2023] [Revised: 01/19/2024] [Accepted: 02/09/2024] [Indexed: 03/03/2024] Open
Abstract
ABSTRACT Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening, hyperinflammatory syndrome. Emapalumab, a fully human monoclonal antibody that neutralizes the proinflammatory cytokine interferon gamma, is approved in the United States to treat primary HLH (pHLH) in patients with refractory, recurrent, or progressive disease, or intolerance with conventional HLH treatments. REAL-HLH, a retrospective study, conducted across 33 US hospitals, evaluated real-world treatment patterns and outcomes in patients treated with ≥1 dose of emapalumab between 20 November 2018 and 31 October 2021. In total, 46 patients met the pHLH classification criteria. Median age at diagnosis was 1.0 year (range, 0.3-21.0). Emapalumab was initiated for treating refractory (19/46), recurrent (14/46), or progressive (7/46) pHLH. At initiation, 15 of 46 patients were in the intensive care unit, and 35 of 46 had received prior HLH-related therapies. Emapalumab treatment resulted in normalization of key laboratory parameters, including chemokine ligand 9 (24/33, 72.7%), ferritin (20/45, 44.4%), fibrinogen (37/38, 97.4%), platelets (39/46, 84.8%), and absolute neutrophil count (40/45, 88.9%). Forty-two (91.3%) patients were considered eligible for transplant. Pretransplant survival was 38 of 42 (90.5%). Thirty-one (73.8%) transplant-eligible patients proceeded to transplant, and 23 of 31 (74.2%) of those who received transplant were alive at the end of the follow-up period. Twelve-month survival probability from emapalumab initiation for the entire cohort (N = 46) was 73.1%. There were no discontinuations because of adverse events. In conclusion, results from the REAL-HLH study, which describes treatment patterns, effectiveness, and outcomes in patients with pHLH treated with emapalumab in real-world settings, are consistent with the emapalumab pivotal phase 2/3 pHLH trial.
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Affiliation(s)
- Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Michael B. Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashley Baker
- Department of Pediatrics, Division of Hematology Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Edward M. Behrens
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deepika Bhatla
- Department of Pediatric Hematology Oncology, Saint Louis University, St. Louis, MO
| | - May Chien
- Department of Hematology-Oncology, Lucile Packard Children's Hospital at Stanford University, Palo Alto, CA
| | - Olive S. Eckstein
- Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Michael M. Henry
- Department of Pediatric Hematology-Oncology, Phoenix Children’s, Phoenix, AZ
| | - Michelle L. Hermiston
- Department of Pediatric Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | - Ashley P. Hinson
- Department of Pediatric Hematology-Oncology, Atrium Health, Levine Children's Hospital, Charlotte, NC
| | - Jennifer W. Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | | | - Sachit A. Patel
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | | | - Anish K. Ray
- Department of Pediatric Hematology-Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Blachy Dávila Saldaña
- Division of Blood and Marrow Transplantation, Children's National Medical Center, Washington, DC
| | - Susmita N. Sarangi
- Department of Pediatric Hematology-Oncology, MedStar Georgetown University Hospital, Washington, DC
| | - Kelly J. Walkovich
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | | | - Adi Zoref-Lorenz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Hematology, Hematology Institute, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carl E. Allen
- Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, TX
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Feng C, Hua Z, He L, Yao S, Zou H, Zhu Y, Wang Z, Wang Y. A convenient and practical index for predicting the induction response in adult patients with hemophagocytic lymphohistiocytosis: ferritin/platelet ratio. Ann Hematol 2024; 103:715-723. [PMID: 38197929 PMCID: PMC10867095 DOI: 10.1007/s00277-023-05606-7] [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: 10/18/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome with high mortality rate. The response to induction therapy is an important factor affecting survival. The purpose is to investigate laboratory predictors for induction response in adult patients with HLH, which are convenient, practical, and timeliness. Clinical data from January 2017 to December 2020 was retrospectively analyzed, and 269 patients were included. Patients were divided into remission and non-remission groups according to their induction response, 177 in the remission group, and 92 in the non-remission group. We reviewed general characteristics and analyzed the predictive value of serum ferritin, triglycerides, alanine aminotransferase (ALT), and blood cells before and 1-4 weeks after induction therapy for induction response by univariate analysis, ROC curves, etc. There was a correlation between serum ferritin, ALT, leukocytes, neutrophils, hemoglobin, platelets, and induction response (P < 0.05). Serum ferritin and platelets 1-4 weeks after induction therapy, respectively, might be a good predictor for induction response in adults with HLH, with AUC values close to or greater than 0.7. We established a new clinical model of the ferritin/platelet ratio. The results showed that the ferritin/platelet ratio at 1-4 weeks after induction therapy might be a practical index for predicting induction response, which significantly improved the area under the ROC curve (AUC > 0.75). Patients with a ferritin/platelet ratio > 16.08 at 2 weeks after induction therapy may have a relatively poor induction response. Ferritin/platelet ratio after induction therapy can be a good predictor for induction response in adult patients with HLH.
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Affiliation(s)
- Cuicui Feng
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
- Department of Hematology, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, 100029, China
| | - Zhengjie Hua
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Lingbo He
- Department of General Medicine, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Shuyan Yao
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Heshan Zou
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Yingxin Zhu
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China.
| | - Yini Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China.
- Department of General Medicine, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China.
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Behrens EM, de Benedetti F. Anti-Interferon-γ Therapy for Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:573-582. [PMID: 39117840 DOI: 10.1007/978-3-031-59815-9_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
A vast body of evidence provides support to a central role of exaggerated production of interferon-γ (IFN-γ) in causing hypercytokinemia and signs and symptoms of hemophagocytic lymphohistiocytosis (HLH). In this chapter, we will describe briefly the roles of IFN-γ in innate and adaptive immunity and in host defense, summarize results from animal models of primary HLH and secondary HLH with particular emphasis on targeted therapeutic approaches, review data on biomarkers associated with activation of the IFN-γ pathway, and discuss initial efficacy and safety results of IFN-γ neutralization in humans.
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Affiliation(s)
- Edward M Behrens
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Cox MF, Mackenzie S, Low R, Brown M, Sanchez E, Carr A, Carpenter B, Bishton M, Duncombe A, Akpabio A, Kulasekararaj A, Sin FE, Jones A, Kavirayani A, Sen ES, Quick V, Dulay GS, Clark S, Bauchmuller K, Tattersall RS, Manson JJ. Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline. THE LANCET. RHEUMATOLOGY 2024; 6:e51-e62. [PMID: 38258680 DOI: 10.1016/s2665-9913(23)00273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 01/24/2024]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by persistently activated cytotoxic lymphocytes and macrophages, which, if untreated, leads to multiorgan dysfunction and death. HLH should be considered in any acutely unwell patient not responding to treatment as expected, with prompt assessment to look for what we term the three Fs-fever, falling blood counts, and raised ferritin. Worldwide, awareness of HLH and access to expert management remain inequitable. Terminology is not standardised, classification criteria are validated in specific patient groups only, and some guidelines rely on specialised and somewhat inaccessible tests. The consensus guideline described in this Health Policy was produced by a self-nominated working group from the UK network Hyperinflammation and HLH Across Speciality Collaboration (HiHASC), a multidisciplinary group of clinicians experienced in managing people with HLH. Combining literature review and experience gained from looking after patients with HLH, it provides a practical, structured approach for all health-care teams managing adult (>16 years) patients with possible HLH. The focus is on early recognition and diagnosis of HLH and parallel identification of the underlying cause. To ensure wide applicability, the use of inexpensive, readily available tests is prioritised, but the role of specialist investigations and their interpretation is also addressed.
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Affiliation(s)
- Miriam F Cox
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Strachan Mackenzie
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ryan Low
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael Brown
- Division of Infection, University College London Hospitals NHS Foundation Trust, London, UK
| | - Emilie Sanchez
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling Carr
- Centre for Neuromuscular Diseases, National hospital of Neurology and Neurosurgery, London, UK
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Bishton
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - Akpabio Akpabio
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - Fang En Sin
- Department of Rheumatology, North Bristol NHS Trust, UK
| | - Alexis Jones
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Akhila Kavirayani
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vanessa Quick
- Department of Rheumatology, Bedfordshire Hospitals NHS Trust, Luton, UK
| | - Gurdeep S Dulay
- Department of Rheumatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Clark
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.
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5
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Barrett D. IL-6 Blockade in Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:565-572. [PMID: 39117839 DOI: 10.1007/978-3-031-59815-9_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Interleukin-6 (IL-6) is a pro-inflammatory cytokine elevated in cytokine storm syndromes, including hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). It is also elevated in cytokine release syndrome (CRS) after immune activating cancer therapies such as chimeric antigen receptor (CAR) T-cells or bispecific T-cell engagers (BITEs) and in some patients after infection with SARS-CoV-2. The interaction of IL-6 with its receptor complex can happen in several forms, making effectively blocking this cytokine's effects clinically challenging. Fortunately, effective clinical agents targeting the IL-6 receptor (tocilizumab) and IL-6 directly (siltuximab) have been developed and are approved for use in humans. IL-6 blockade has now been used to safely and effectively treat several cytokine storm syndromes (CSS). Other methods of investigation in effective IL-6 blockade are underway.
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Affiliation(s)
- David Barrett
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
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6
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Wang S, Lv K, Zhou Y, Cheng X, Chen Z, Shen H, Li F. A novel prognosis-prediction model based on coagulation indicators in secondary hemophagocytic lymphohistiocytosis. Ann Hematol 2023; 102:3251-3259. [PMID: 37561154 PMCID: PMC10567857 DOI: 10.1007/s00277-023-05398-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/01/2023] [Indexed: 08/11/2023]
Abstract
Secondary hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease. In the present retrospective study, we aimed to investigate coagulation disorders and their outcome implications in patients with secondary HLH. We evaluated clinical characteristics and the relationship between coagulation indices and prognosis in HLH patients (n = 141). The information, including clinical symptoms, laboratory indicators, and coagulation indices, was evaluated. Coagulation disorders and bleeding events occurred in 95 (67.4%) and 60 (42.6%) patients, respectively. A coagulation index analysis primarily showed elevated levels of D-Dimer, the international standardized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), and thrombin time (TT), while the prothrombin activity, fibrinogen levels, and platelet levels were significantly decreased. Dominant disseminated intravascular coagulation (DIC) occurred in 76 patients (53.9%). Patients with lymphoma-associated hemophagocytic syndrome (LAHS) frequently exhibited apparent coagulation disorders. Multivariate analysis revealed that age ≥ 29.5 years, bleeding events, APTT ≥ 47.3 s, fibrinogen ≤ 1.68 g/L, and absolute neutrophil counts (ANC) of ≤ 1.21 × 109/L were independent prognostic factors. We thereby devised a prognostic scoring system and stratified patients into low-risk (0-2 points), intermediate-risk (3-4 points), and high-risk (5-7 points) groups, and the 1-year overall survival rates in the above-mentioned groups were 66.40%, 40.00%, and 2.30%, respectively (P < 0.0001). In conclusion, coagulation dysfunctions and bleeding tendencies were common characteristics in HLH patients. We constructed a novel prognostic score model based on APTT, fibrinogen level, ANC, age, and bleeding events, which had superior prognostic value compared with these markers alone.
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Affiliation(s)
- Shixuan Wang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Kebing Lv
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yulan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Xiaoye Cheng
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhiwei Chen
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Huimin Shen
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China.
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China.
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China.
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7
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Qiu Q, Li D, Chen Y, Song Y, Lou S, Zhou K, Deng J. Clinical features and prognostic risk prediction of adult hemophagocytic lymphohistiocytosis: a 9-year retrospective study. Ann Hematol 2023; 102:2671-2682. [PMID: 37464139 DOI: 10.1007/s00277-023-05368-2] [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: 02/07/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has a low incidence and high mortality. In order to improve our understanding of the clinical features and prognostic risk factors of adult HLH, we analyzed the clinical characteristics and prognostic risk factors of adult HLH and developed a prognostic model to predict the overall survival (OS) of adult HLH. The clinical characteristics and survival statistics of adult patients with HLH identified at The Second Affiliated Hospital of Chongqing Medical University between February 2012 and October 2020 were retrospectively analyzed to constitute the primary cohort, while patients between 25 October 2020 and 20 March 2023 were collected at the same institution as a validation cohort for the prospective study. A total of 142 patients met the inclusion criteria, with 72 and 70 in the primary cohort and validation cohort respectively. In the primary cohort, the median OS was 102 days, with 37.5%, 34.5%, and 28.7% 1-, 2-, and 3-year OS, respectively. Univariate analysis showed that age, interleukin-10 (IL-10), interleukin-2 receptor (IL-2R), prothrombin time (PT), and indirect bilirubin (IBiL) were correlated with prognosis. Multivariate analysis showed that IL-10 and PT were independent factors affecting OS in adult patients with HLH. A prognostic model consisting of IL-2R, PT, and IL-10 and a corresponding prognostic nomogram were developed adopting the principle of minimum value of Akaike information criterion(AIC). The model has a high prediction accuracy letter (C-index = 0.708). The AUC values of 1-year, 2-year, and 3-year were 0.826, 0.865, and 0.882, correspondingly. In the validation cohort, all patients were divided into high-risk and low-risk groups, and the risk of death was significantly higher in the high-risk group than in the low-risk group (p < 0.01). The calibration curve for the model shows that the Nomogram constructed in this study is very reliable to predict the OS of HLH patients. IL-10 and PT have significant prognostic value in adult HLH. The prognostic model and the nomogram built in this study can forecast the OS of adult HLH patients.
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Affiliation(s)
- Qunxiang Qiu
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dan Li
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Song
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Kang Zhou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Jianchuan Deng
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS). Arthritis Rheumatol 2023; 75:1714-1732. [PMID: 37486733 PMCID: PMC11040593 DOI: 10.1002/art.42636] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, NIH, Bethesda, Maryland
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, and Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hines
- Pediatric Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University and Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children’s Hospital, Houston
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward M. Behrens
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Randy Q. Cron
- Pediatric Rheumatology, University of Alabama at Birmingham
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California
| | - Alexei A. Grom
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Lauren A. Henderson
- Pediatric Immunology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annacarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B. Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Kim E. Nichols
- Division of Cancer Predisposition Department of Oncology, St. Jude Children’s Research Hospital Department of Oncology, Memphis, Tennessee
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | | | - Rebecca A. Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Scott W. Canna
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). Ann Rheum Dis 2023; 82:1271-1285. [PMID: 37487610 PMCID: PMC11017727 DOI: 10.1136/ard-2023-224123] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa Hines
- Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children's Hospital, Houston, Texas, USA
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California, USA
| | - Alexei A Grom
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren A Henderson
- Pediatric Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Annacarin Horne
- Department of Women's and Children's Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Kim E Nichols
- Division of Cancer Predisposition Department of Oncology, St Jude Children's Research Hospital Department of Oncology, Memphis, Tennessee, USA
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Rebecca A Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Scott W Canna
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Mangoni AA, Zinellu A. A systematic review and meta-analysis of neopterin in rheumatic diseases. Front Immunol 2023; 14:1271383. [PMID: 37799718 PMCID: PMC10548830 DOI: 10.3389/fimmu.2023.1271383] [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: 08/02/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Introduction Novel biomarkers of inflammation and oxidative stress might enhance the early recognition, management, and clinical outcomes of patients with rheumatic diseases (RDs). We assessed the available evidence regarding the pathophysiological role of neopterin, the oxidation product of 7,8-dihydroneopterin, a pteridine generated in macrophages activated by interferon-γ, by conducting a systematic review and meta-analysis of studies reporting its concentrations in biological fluids in RD patients and healthy controls. Methods We searched electronic databases for relevant articles published between inception and 31 August 2023. The risk of bias and the certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and the Grades of Recommendation, Assessment, Development and Evaluation Working Group system, respectively. Results In 37 studies, when compared to healthy controls, RD patients had significantly higher concentrations of neopterin both in plasma or serum (standard mean difference, SMD=1.31, 95% CI 1.01 to 1.61; p<0.001; moderate certainty of evidence) and in the urine (SMD=1.65, 95% CI 0.86 to 2.43, p<0.001; I2 = 94.2%, p<0.001; low certainty of evidence). The results were stable in sensitivity analysis. There were non-significant associations in meta-regression and subgroup analysis between the effect size and age, male to female ratio, year of publication, sample size, RD duration, C-reactive protein, erythrocyte sedimentation rate, specific type of RD, presence of connective tissue disease, analytical method used, or biological matrix investigated (plasma vs. serum). By contrast, the effect size was significantly associated with the geographical area in studies assessing serum or plasma and with the type of RD in studies assessing urine. Discussion Pending additional studies that also focus on early forms of disease, our systematic review and meta-analysis supports the proposition that neopterin, a biomarker of inflammation and oxidative stress, can be useful for the identification of RDs. (PROSPERO registration number: CRD42023450209). Systematic review registration PROSPERO, identifier CRD42023450209.
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Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
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He L, Yang C, Wang Y. Biological therapies for hemophagocytic lymphohistiocytosis: current knowledge and future perspectives. Expert Opin Biol Ther 2023; 23:1005-1013. [PMID: 37614018 DOI: 10.1080/14712598.2023.2251885] [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: 06/25/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome with a dismal prognosis. The underlying causes of HLH are diverse. However, the overabundance of cytokines was shared by all forms of HLH. Cytokine-targeted biotherapies have been increasingly used in HLH treatment. AREAS COVERED In this review, we aim to provide an overview of biological treatment options for HLH. EXPERT OPINION Biological therapies offer alternative treatment options for patients with refractory/relapsed HLH or who are intolerant to conventional chemotherapies. As a complement to traditional treatment, biological agents improve response rates, maintain more protracted periods of remission, and reduce treatment related toxicity. A combination of biological agents may be a promising direction for HLH treatment. However, they may induce HLH to deteriorate and even trigger HLH.
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Affiliation(s)
- Lingbo He
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chun Yang
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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12
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Ou W, Zhao Y, Wei A, Ma H, Zhang Q, Zhang L, Lian H, Wang D, Li Z, Wang T, Zhang R. Serum cytokine pattern in children with hemophagocytic lymphohistiocytosis. Ann Hematol 2023; 102:729-739. [PMID: 36792730 PMCID: PMC9931565 DOI: 10.1007/s00277-023-05132-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
This study aimed to compare the serum levels of 34 cytokines of children with hemophagocytic lymphohistiocytosis (HLH) and explored the specific cytokine pattern of HLH subtypes and the relationship between cytokine levels and prognosis. This retrospective study assessed the clinical data and cytokine levels of newly diagnosed children with HLH in Beijing Children's Hospital, Capital Medical University, from January 2017 to December 2021. A total of 101 children were enrolled in the study. The levels of IFN-γ and IL-18 increased in more than 90% of patients, and MIP-1α, SDF-1α, IP-10, IL-6, IL-8, IL-10, IL-1 RA, and TNF-α increased at different levels in more than 50% of patients. The levels of IL-10 in EBV-HLH increased significantly, followed by IFN-γ and IL-18, while IL-10 and IFN-γ in CAEBV-HLH had a slight increase. Except for IL-10, the levels of IL-6, Eotaxin, IL-13, IL-18, IFN-γ, and MIP-1β in Rh-HLH increased significantly. F-HLH had significantly high IL-10 levels and a slight increase in IL-13. We showed that various cytokines could assist in differentiating HLH subtypes with ROC curve analysis. When IL-10/IL-6 was 1.37, the sensitivity and specificity of diagnosing EBV-HLH were higher than 80% (AUC = 0.837, p < 0.001). The effect of cytokine ratio on classifying HLH subtypes (17/22, 77.3%) was more significant than the single cytokine (5/22, 22.7%). The 3-year overall survival (OS) rate of children with F-HLH was the lowest during the follow-up. The 3-year OS of patients with EBV-HLH and CAEBV-HLH was significantly higher than that with F-HLH (88.1% ± 5.0% vs. 94.1% ± 5.7% vs. 57.1% ± 14.6%, p = 0.017). Cox proportional hazards model revealed that elevated GM-CSF and MCP-1, as well as CNS involvement, were independent risk factors for poor outcomes for patients with HLH. Various cytokines play important roles in HLH. Different subtypes of HLH have their specific cytokines pattern, and the ratio of cytokines may be more significant in differentiating HLH subtypes than the single one. Elevated GM-CSF and MCP-1 could be useful biomarkers for a poor prognosis for patients with HLH.
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Affiliation(s)
- Wenxin Ou
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Yunze Zhao
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Ang Wei
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Honghao Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Qing Zhang
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute;Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Liping Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Hongyun Lian
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Dong Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Zhigang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute;Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China.
| | - Tianyou Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China.
| | - Rui Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Disease in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China.
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Irino K, Jinnouchi F, Nakano S, Sawabe T. A case of hemophagocytic lymphohistiocytosis with a significant response to baricitinib: a first report with review of literature. Clin Rheumatol 2023:10.1007/s10067-023-06579-8. [PMID: 36947281 DOI: 10.1007/s10067-023-06579-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/23/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a febrile disease with hyperinflammation characterized by activated macrophages with phagocytosis. The treatment strategy of secondary HLH has not been clearly established. Because of the high mortality rate and poor prognosis of HLH, alternative treatment strategies have been sought in treatment-resistant cases. Recently, there have been several reports that ruxolitinib, a Janus kinase (JAK) 1/JAK2 inhibitor, was effective against secondary HLH. Since the pathogenesis of HLH involves the overproduction of cytokines and JAK transmits a variety of cytokine signals, JAK inhibitors are thought to be effective in HLH. We herein report a case of HLH that was refractory to glucocorticoids, cyclosporine, and etoposide but responded to baricitinib. In the field of rheumatology, treatment-resistant cases of secondary HLH remain unmet needs. This is the first report to show that baricitinib was effective in a case of HLH. The accumulation of more cases in the future may prove that baricitinib is a potent agent for treating HLH.
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Affiliation(s)
- Kensuke Irino
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan.
| | - Fumiaki Jinnouchi
- Department of Hematology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Shota Nakano
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan
| | - Takuya Sawabe
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [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: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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Cytokine nanosponges suppressing overactive macrophages and dampening systematic cytokine storm for the treatment of hemophagocytic lymphohistiocytosis. Bioact Mater 2023; 21:531-546. [PMID: 36185750 PMCID: PMC9508173 DOI: 10.1016/j.bioactmat.2022.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a highly fatal condition with the positive feedback loop between continued immune cell activation and cytokine storm as the core mechanism to mediate multiple organ dysfunction. Inspired by macrophage membranes harbor the receptors with special high affinity for proinflammation cytokines, lipopolysaccharide (LPS)-stimulated macrophage membrane-coated nanoparticles (LMNP) were developed to show strong sponge ability to both IFN-γ and IL-6 and suppressed overactivation of macrophages by inhibiting JAK/STAT signaling pathway both in vitro and in vivo. Besides, LMNP also efficiently alleviated HLH-related symptoms including cytopenia, hepatosplenomegaly and hepatorenal dysfunction and save the life of mouse models. Furthermore, its sponge effect also worked well for five human HLH samples in vitro. Altogether, it's firstly demonstrated that biocompatible LMNP could dampen HLH with high potential for clinical transformation, which also provided alternative insights for the treatment of other cytokine storm-mediated pathologic conditions such as COVID-19 infection and cytokine releasing syndrome during CAR-T therapy. LMNP functioned better as a multiple-cytokine sponging tool when compared with conventional macrophage coated nanoparticles. LMNP sponged inflammation cytokines and suppressed macrophage overactivation by inhibiting JAK/STAT signaling pathway. LMNP calmed down systematic cytokine storm and dampened HLH in HLH mice models. LMNP also worked well in sponging cytokines in human HLH samples which indicated high potential of clinical transformation.
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Recent advances in the treatment of hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Curr Opin Allergy Clin Immunol 2022; 22:364-370. [PMID: 36206094 DOI: 10.1097/aci.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PURPOSE OF REVIEW The approach to treating patients with hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) has shifted in recent years with the aim to limit exposure to genotoxic agents, such as etoposide, yet dampen hyperinflammation by targeting the activity of specific HLH/MAS-associated cytokines. In this review, we discuss recent efforts to reduce the dose of etoposide and/or incorporate cytokine-targeted therapies for the treatment of HLH/MAS. RECENT FINDINGS There is emerging evidence that reduced-dose etoposide and/or cytokine-targeted therapies, including agents that neutralize or inhibit signaling induced by interferon gamma, interleukin (IL)-1, IL-18, and IL-6, can effectively ameliorate the clinical and laboratory manifestations of HLH/MAS and improve overall outcomes. SUMMARY The application of novel regimens containing lower doses of etoposide and/or cytokine-directed agents to treat HLH/MAS holds potential to dampen inflammation while minimizing therapy-associated toxicities. Nevertheless, further research is needed to better understand, which patients represent the most appropriate candidates to receive cytokine-targeted therapies, elucidate the optimal timing and dose of these therapies, and decipher whether they should be administered alone or in combination with conventional HLH-directed therapies, such as dexamethasone and standard-dose or reduced-dose etoposide.
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Kocivnik N, Velnar T. A Review Pertaining to SARS-CoV-2 and Autoimmune Diseases: What Is the Connection? LIFE (BASEL, SWITZERLAND) 2022; 12:life12111918. [PMID: 36431053 PMCID: PMC9698792 DOI: 10.3390/life12111918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is an infectious viral disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It is known that infection with SARS-CoV-2 can lead to various autoimmune and autoinflammatory diseases. There are few reports in the literature on the association between SARS-CoV-2 and autoimmune diseases, and the number of reports has been increasing since 2020. Autoimmune diseases and SARS-CoV-2 infections are intertwined in several ways. Both conditions lead to immune-mediated tissue damage, the immune response is accompanied by the increased secretion of inflammatory cytokines and both conditions can be treated using immunomodulatory drugs. Patients with certain autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes, cardiac sarcoidosis, idiopathic pulmonary fibrosis, autoimmune hepatitis, multiple sclerosis and others, are more susceptible to SARS-CoV-2 infection, either because of the active autoimmune disease or because of the medications used to treat it. Conversely, SARS-CoV-2 infection can also cause certain autoimmune diseases. In this paper, we describe the development of autoimmune diseases after COVID-19 and the recovery from COVID-19 in people with autoimmune diseases.
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Affiliation(s)
- Nina Kocivnik
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
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Jin Z, Suolitiken D, Wang Y, Wang Z. The diagnostic importance of multiple cytokines in adult hemophagocytic lymphohistiocytosis. J Clin Lab Anal 2022; 37:e24669. [PMID: 36036769 PMCID: PMC10156101 DOI: 10.1002/jcla.24669] [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: 03/13/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a category of immunological illnesses that cause out-of-control T cells and macrophages to release life-threatening cytokines. The HLH-2004 diagnostic criteria are the gold standard for HLH diagnosis, but there is a need to investigate the usefulness of various cytokines for HLH diagnosis. METHODS Patients admitted to Beijing Friendship Hospital of Capital Medical University from January 2016 to December 2020 were included in this retrospective study, with 166 patients with confirmed HLH and 142 febrile patients requiring differential diagnosis completing the sum. Multiplex cytokine assays using multifactor liquid phase microarray technology-based multifactor liquid phase microarray technology were used to detect 33 cytokines. Twenty-eight cytokines detected using the Luminex analytical platform technology were ultimately included in the analysis. RESULTS Interleukin-1 receptor antagonist (IL-1 RA), IL-18, interferon-γ (IFN-γ), and interferon-induced protein 10 (IP-10) regulated upon activation normal T cell expressed and secreted (RANTES), eotaxin, growth-related oncogene α (GRO-α), and macrophage inflammatory protein-1 α (MIP-1α) were higher in the HLH group than in the non-HLH group, and the differences were statistically significant. Among them, the area under the curve (AUC) for IL-18 for HLH diagnosis was reported for the first time as 82.69%, with a sensitivity of 76.32% and a specificity of 79.61%; the AUC of IL-1 RA was 72.34%, with a sensitivity of 62.71% and a specificity of 75.97%; and the AUC of IP-10 was 71.73%, with a sensitivity of 60.14% and a specificity of 75.15%. Moreover, the AUC of the combined diagnostic tests for IL-1 RA, IL-18, IFN-γ, IP-10, and RANTES was 99.6%, with a sensitivity of 95.8% and a specificity of 98.6%. CONCLUSION Our study concluded that multiple cytokines are valid biological markers for the diagnosis of HLH. The findings of this study remain to be validated in an external dataset.
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Affiliation(s)
- Zhili Jin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dina Suolitiken
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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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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Xu XJ, Luo ZB, Song H, Xu WQ, Henter JI, Zhao N, Wu MH, Tang YM. Simple Evaluation of Clinical Situation and Subtypes of Pediatric Hemophagocytic Lymphohistiocytosis by Cytokine Patterns. Front Immunol 2022; 13:850443. [PMID: 35296096 PMCID: PMC8918565 DOI: 10.3389/fimmu.2022.850443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundHemophagocytic lymphohistiocytosis (HLH) is a rapidly fatal disease caused by immune dysregulation. Early initiation of treatment is imperative for saving lives. However, a laboratory approach that could be used to quickly evaluate the HLH subtype and clinical situation is lacking. Our previous studies indicated that cytokines such as interferon (IFN)-γ and interleukin (IL)-10 were helpful for the early diagnosis of HLH and were associated with disease severity. The purpose of this study is to clarify the different cytokine patterns of various subtypes of pediatric HLH and to investigate the role of cytokines in a simple evaluation of disease feature.Patients and MethodsWe enrolled 256 pediatric patients with newly diagnosed HLH. The clinical features and laboratory findings were collected and compared among different subtypes of HLH. A model integrating cytokines was established to stratify HLH patients into different clinical groups.ResultsTwenty-seven patients were diagnosed with primary HLH (pHLH), 179 with EBV-HLH, and 50 with other causes. The IL-6, IL-10, and IFN-γ levels and the ratios of IL-10 to IFN-γ were different among EBV-HLH, other infection-associated HLH, malignancy-associated HLH, familial HLH, and X-linked lymphoproliferative disease. Patients with the ratio of IL-10 to IFN-γ >1.33 and the concentration of IFN-γ ≤225 pg/ml were considered to have pHLH, with a sensitivity of 73% and a specificity of 84%. A four-quadrant model based on the two cutoff values was established to stratify the patients into different clinical situations. The HLH subtypes, cytokine levels, treatment regimens, treatment response, and outcomes were different among the four quadrants, with the 8-week mortality from 2.9 ± 2.9% to 21.4 ± 5.5% and the 5-year overall survival from 93.9 ± 4.2% to 52.6 ± 7.1%.ConclusionsDifferent subtypes of HLH present distinct cytokine patterns. IFN-γ and the ratio of IL-10 to IFN-γ are helpful tools to differentiate HLH subtypes. A four-quadrant model based on these two parameters is a useful tool for a simple evaluation of the HLH situation.
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Affiliation(s)
- Xiao-Jun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ze-Bin Luo
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hua Song
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Wei-Qun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Oncology, Theme of Children’s Health, Karolinska University Hospital, Stockholm, Sweden
| | - Ning Zhao
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meng-Hui Wu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yong-Min Tang
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
- *Correspondence: Yong-Min Tang,
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21
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Anderko RR, Gómez H, Canna SW, Shakoory B, Angus DC, Yealy DM, Huang DT, Kellum JA, Carcillo JA, Angus DC, Barnato AE, Eaton TL, Gimbel E, Huang DT, Keener C, Kellum JA, Landis K, Pike F, Stapleton DK, Weissfeld LA, Willochell M, Wofford KA, Yealy DM, Kulstad E, Watts H, Venkat A, Hou PC, Massaro A, Parmar S, Limkakeng AT, Brewer K, Delbridge TR, Mainhart A, Chawla LS, Miner JR, Allen TL, Grissom CK, Swadron S, Conrad SA, Carlson R, LoVecchio F, Bajwa EK, Filbin MR, Parry BA, Ellender TJ, Sama AE, Fine J, Nafeei S, Terndrup T, Wojnar M, Pearl RG, Wilber ST, Sinert R, Orban DJ, Wilson JW, Ufberg JW, Albertson T, Panacek EA, Parekh S, Gunn SR, Rittenberger JS, Wadas RJ, yEdwards AR, Kelly M, Wang HE, Holmes TM, McCurdy MT, Weinert C, Harris ES, Self WH, Phillips CA, Migues RM. Sepsis with liver dysfunction and coagulopathy predicts an inflammatory pattern of macrophage activation. Intensive Care Med Exp 2022; 10:6. [PMID: 35190900 PMCID: PMC8861227 DOI: 10.1186/s40635-022-00433-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Background Interleukin-1 receptor antagonists can reduce mortality in septic shock patients with hepatobiliary dysfunction and disseminated intravascular coagulation (HBD + DIC), an organ failure pattern with inflammatory features consistent with macrophage activation. Identification of clinical phenotypes in sepsis may allow for improved care. We aim to describe the occurrence of HBD + DIC in a contemporary cohort of patients with sepsis and determine the association of this phenotype with known macrophage activation syndrome (MAS) biomarkers and mortality. We performed a retrospective nested case–control study in adult septic shock patients with concurrent HBD + DIC and an equal number of age-matched controls, with comparative analyses of all-cause mortality and circulating biomarkers between the groups. Multiple logistic regression explored the effect of HBD + DIC on mortality and the discriminatory power of the measured biomarkers for HBD + DIC and mortality. Results Six percent of septic shock patients (n = 82/1341) had HBD + DIC, which was an independent risk factor for 90-day mortality (OR = 3.1, 95% CI 1.4–7.5, p = 0.008). Relative to sepsis controls, the HBD + DIC cohort had increased levels of 21 of the 26 biomarkers related to macrophage activation (p < 0.05). This panel was predictive of both HBD + DIC (sensitivity = 82%, specificity = 84%) and mortality (sensitivity = 92%, specificity = 90%). Conclusion The HBD + DIC phenotype identified patients with high mortality and a molecular signature resembling that of MAS. These observations suggest trials of MAS-directed therapies are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00433-y.
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22
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Lu X, Wei A, Yang X, Liu J, Li S, Kan Y, Wang W, Wang T, Zhang R, Yang J. The Role of Pre-therapeutic 18F-FDG PET/CT in Pediatric Hemophagocytic Lymphohistiocytosis With Epstein-Barr Virus Infection. Front Med (Lausanne) 2022; 8:836438. [PMID: 35127776 PMCID: PMC8813965 DOI: 10.3389/fmed.2021.836438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the role of pre-therapeutic 18F-FDG PET/CT in pediatric hemophagocytic lymphohistiocytosis (HLH) with Epstein-Barr virus (EBV) infection. Methods This retrospective study included 29 HLH children (1–16 years) with EBV infection, who underwent pre-therapeutic 18F-FDG PET/CT from July 2018 to November 2020. Pathology results were considered as the reference standard. These patients were divided into two groups: EBV-induced malignancy-associated HLH (M-HLH, N = 9) and EBV-induced non-malignancy-associated HLH (NM-HLH, N = 20). The regions of interest (ROIs) of the liver, spleen (Sp), bone marrow (BM), lymph nodes (LN), hypermetabolic lesions, liver background (LiBG), and mediastinum (M) were drawn with software 3D-Slicer. The volumetric and metabolic parameters, including maximum standard uptake value (SUVmax), metabolic tumor volume, and total lesion glycolysis of these ROIs, clinical parameters, and laboratory parameters were compared between the two groups. The efficiency of the above parameters in predicting the treatment response and overall survival (OS) was analyzed. Results Receiver operating characteristic curve analysis indicated that SUVmax-lesions and SUVmax-LN/M (AUC = 0.822, 0.819, cut-off = 6.04, 5.74, respectively) performed better in differentiating M-HLH from NM-HLH. It had the best diagnostic performance when age was added with the SUVmax-LN/M (AUC = 0.933, sensitivity = 100%, specificity = 85.0%). The presence of extranodal hypermetabolic lesions in multiple organs indicated the M-HLH (P = 0.022). Older age, higher SUVmax-LN and SUVmax-lesions, and the presence of serous effusion were associated with poorer treatment response at the 2nd and 4th week (not reaching partial remission). Multivariate analysis showed that SUVmax-lesions > 7.66 and SUVmax-Sp/LiBG > 2.01 were independent prognostic factors for overall survival (P = 0.025, 0.036, respectively). Conclusions 18F-FDG PET/CT could be a valuable technique for identifying the underlying malignancy and predicting prognosis in pediatric HLH with EBV infection. M-HLH could be considered when SUVmax-lesions > 6.04, SUVmax-LN/M > 5.74, and the presence of extranodal hypermetabolic lesions in multiple organs on 18F-FDG PET/CT. SUVmax-lesions and SUVmax-Sp/LiBG might be independent prognostic factors for OS.
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Affiliation(s)
- Xia Lu
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Ang Wei
- National Center for Children's Health, Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xu Yang
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Jun Liu
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Siqi Li
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Ying Kan
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Wei Wang
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Tianyou Wang
- National Center for Children's Health, Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Rui Zhang
- National Center for Children's Health, Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
- Rui Zhang
| | - Jigang Yang
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
- *Correspondence: Jigang Yang
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23
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Cui Y, Shi J, Lu G, Wang Y, Zhu X, Ren H, Zhu Y, Yan G, Wang C, Zhang Y. Prognostic death factors in secondary hemophagocytic lymphohistiocytosis children with multiple organ dysfunction syndrome receiving continuous renal replacement therapy: A multicenter prospective nested case-control study. Ther Apher Dial 2021; 26:1023-1029. [PMID: 34877787 PMCID: PMC9540864 DOI: 10.1111/1744-9987.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/30/2022]
Abstract
Introduction Multiple organ dysfunction syndrome (MODS) with secondary hemophagocytic lymphohistiocytosis (SHLH) causes significant mortality. We aimed to identify the predictor factors for death in pediatric patients with SHLH‐associated MODS receiving continuous renal replacement therapy (CRRT). Methods This multicentered nested case–control study was conducted from 2016 to 2020. The characteristics were compared between survivors and non‐survivors. Logistic regression was applied to identify the risk factors for death. The cutoff values were assessed by receiver operating characteristics curves. Results Fifty two patients were enrolled in this study. Interleukin‐6 level (p = 0.018) and the number of organ dysfunction (p = 0.047) were independent risk factors for death. The cutoff value of 13.12 pg/ml interleukin‐6 and three organs dysfunction at CRRT initiation presented a high sensitivity and specificity. Conclusion The number of organ dysfunction and interleukin‐6 at CRRT initiation are independent risk factors for death in pediatric patients with SHLH‐associated MODS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Guoping Lu
- Department of Critical Care Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Wang
- Department of Critical Care Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Ren
- Department of Critical Care Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gangfeng Yan
- Department of Critical Care Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
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24
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Targeting interferon-γ in hyperinflammation: opportunities and challenges. Nat Rev Rheumatol 2021; 17:678-691. [PMID: 34611329 DOI: 10.1038/s41584-021-00694-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Interferon-γ (IFNγ) is a pleiotropic cytokine with multiple effects on the inflammatory response and on innate and adaptive immunity. Overproduction of IFNγ underlies several, potentially fatal, hyperinflammatory or immune-mediated diseases. Several data from animal models and/or from translational research in patients point to a role of IFNγ in hyperinflammatory diseases, such as primary haemophagocytic lymphohistiocytosis, various forms of secondary haemophagocytic lymphohistiocytosis, including macrophage activation syndrome, and cytokine release syndrome, all of which are often managed by rheumatologists or in consultation with rheumatologists. Given the effects of IFNγ on B cells and T follicular helper cells, a role for IFNγ in systemic lupus erythematosus pathogenesis is emerging. To improve our understanding of the role of IFNγ in human disease, IFNγ-related biomarkers that are relevant for the management of hyperinflammatory diseases are progressively being identified and studied, especially because circulating levels of IFNγ do not always reflect its overproduction in tissue. These biomarkers include STAT1 (specifically the phosphorylated form), neopterin and the chemokine CXCL9. IFNγ-neutralizing agents have shown efficacy in the treatment of primary haemophagocytic lymphohistiocytosis in clinical trials and initial promising results have been obtained in various forms of secondary haemophagocytic lymphohistiocytosis, including macrophage activation syndrome. In clinical practice, there is a growing body of evidence supporting the usefulness of circulating CXCL9 levels as a biomarker reflecting IFNγ production.
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25
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Sepiashvili L, Alli Z, Bohn MK, Hall A, Karin A, Murata K, Adeli K. Complex biological patterns of soluble cytokines and CD163 in childhood necessitating age-specific reference intervals for evidence-based clinical interpretation. Clin Biochem 2021; 98:35-41. [PMID: 34509468 DOI: 10.1016/j.clinbiochem.2021.09.004] [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: 06/22/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cytokine measurements to support clinical laboratory and research investigations have become increasingly common in pediatrics. However, there is a paucity of accurate pediatric reference intervals (RIs) essential to the interpretation of cytokine results. To address this gap, here, we establish age- and sex-specific pediatric reference values for clinically relevant inflammatory markers including CD163, and the cytokines IL-1β, IL-6, IL-10, IL-18, TNF-α, IFN-γ, and CXCL-9. METHODS Healthy children and adolescents (n = 311, 1-19 years) were recruited as part of the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) study. Multi-analyte measurements in plasma and analytical performance verification were conducted on the ProteinSimple® Ella™ automated immunoassay platform (Bio-Techne, MN, USA). Age- and sex-specific RIs were calculated based on Clinical and Laboratory Standards Institute guidelines. Additionally, 75th and 95th percentile cut-offs were determined. RESULTS Three types of reference value distributions were observed: (a) consistent levels throughout age and sex: IL-6, and IFN-γ, (b) gradual decline in concentration with age: CD163, TNF-α, CXCL-9, and IL-10, (c) significantly higher concentrations during ages 4-14 years than earlier and later ages: IL-1β and IL-18. Reference values for CXCL-9, IL-10, and TNF-α under 8 years of age differed significantly from older children. CD163, IL-18 and IL-1β required three age partitions. CD163 demonstrated significant sex differences in ages 8-13 years. CONCLUSION The circulating profile of cytokines in children is complex and can vary by age and sex. This necessitates careful interpretation of test results based on age and/or sex specific RIs facilitating more accurate clinical decision making.
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Affiliation(s)
- Lusia Sepiashvili
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada; SickKids Research Institute, 686 Bay Street, Toronto, ON M5G 0A4, Canada.
| | - Zaman Alli
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Mary Kathryn Bohn
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada
| | - Alexandra Hall
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Amir Karin
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Kazunori Murata
- Memorial Sloan Kettering Cancer Center, 327 E 64th St, New York, NY 10065, USA
| | - Khosrow Adeli
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada; SickKids Research Institute, 686 Bay Street, Toronto, ON M5G 0A4, Canada
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Zhou Y, Kong F, Wang S, Yu M, Xu Y, Kang J, Tu S, Li F. Increased levels of serum interleukin-10 are associated with poor outcome in adult hemophagocytic lymphohistiocytosis patients. Orphanet J Rare Dis 2021; 16:347. [PMID: 34348761 PMCID: PMC8336343 DOI: 10.1186/s13023-021-01973-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Interleukin-10 (IL-10) is an independent factor for predicting adverse outcomes in pediatric patients with hemophagocytic lymphohistiocytosis (HLH). However, little is known about its prognostic value in adult patients. METHODS This single center retrospective study was conducted to explore the prognostic value of IL-10 in 101 adults newly diagnosed with HLH. The serum interleukin levels were quantitatively determined by chemiluminescence using cytokine profiling kits. RESULTS Serum IL-10 levels were significantly increased in adult HLH patients. Elevated IL-10 levels was correlated with lower concentrations of hemoglobin (r = - 0.279, P = 0.005). IL-10 levels were significantly lower in patients with macrophage activation syndrome (MAS) than in those with infection-associated HLH (IAHS) and malignancy-associated HLH (MAHS) (P = 0.033, P = 0.012). Patients with MAS had relatively longer survival than those with IAHS and MAHS (P < 0.001). Univariate analysis indicated that hemoglobin < 8.2 g/dL, platelets < 40 × 109/L, lactate dehydrogenase ≥ 700 IU/L, albumin < 28 g/L, post-treatment ferritin > 1050 µg/L and IL-10 ≥ 129 pg/mL were poor prognostic factors for survival. However, multivariate analysis revealed that only high serum IL-10 levels (≥ 129 pg/mL) at diagnosis and high post-treatment ferritin levels (> 1050 µg/L) were independent risk factors for poor overall survival in adult HLH patients (HR: 4.087, 95% CI 2.064-8.090, P < 0.001; HR 3.814, 95% CI 2.042-7.126, P < 0.001, respectively). CONCLUSIONS Our results suggest that higher serum IL-10 levels might be a prognostic marker in adult HLH patients.
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Affiliation(s)
- Yulan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Fancong Kong
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Shixuan Wang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Min Yu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Yawen Xu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Jing Kang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Songtao Tu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China. .,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China.
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27
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Valade S, Joly BS, Veyradier A, Fadlallah J, Zafrani L, Lemiale V, Launois A, Stepanian A, Galicier L, Fieschi C, Mirouse A, Tudesq JJ, Lepretre AC, Azoulay E, Darmon M, Mariotte E. Coagulation disorders in patients with severe hemophagocytic lymphohistiocytosis. PLoS One 2021; 16:e0251216. [PMID: 34343182 PMCID: PMC8330932 DOI: 10.1371/journal.pone.0251216] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/14/2021] [Indexed: 01/13/2023] Open
Abstract
Background Coagulation disorders are common in patients with hemophagocytic lymphohistiocytosis (HLH), associated with an increased risk of bleeding and death. We aim to investigate coagulation disorders and their outcome implications in critically ill patients with HLH. Methods We prospectively evaluated 47 critically ill patients with HLH (median age of 54 years [42–67]) between April 2015 and December 2018. Coagulation assessments were performed at day 1. Abnormal standard coagulation was defined as prothrombin time (PT) <50% and/or fibrinogen <2g/L. HLH aetiology was mostly ascribed to haematological malignancies (74% of patients). Results Coagulation disorders and severe bleeding events were frequent, occurring in 30 (64%) and 11 (23%) patients respectively. At day 1, median fibrinogen level was 2∙65g/L [1.61–5.66]. Fibrinolytic activity was high as suggested by increased median levels of D-dimers, fibrin monomers, PAI-1 (plasminogen activator inhibitor) and tPA (tissue plasminogen activator). Forty-one (91%) patients had a decreased ADAMTS13 activity (A Disintegrin-like And Metalloproteinase with ThromboSpondin type 1 repeats, member 13). By multivariable analysis, the occurrence of a severe bleeding (OR 3.215 [1.194–8.653], p = 0∙021) and SOFA score (Sepsis-Related Organ Failure Assessment) at day 1 (OR 1.305 per point [1.146–1.485], p<0∙001) were independently associated with hospital mortality. No early biological marker was associated with severe bleeding. Conclusions Hyperfibrinolysis may be the primary mechanism responsible for hypofibrinogenemia and may also participate in ADAMTS13 degradation. Targeting the plasmin system appears as a promising approach in severe HLH-related coagulation disorders.
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Affiliation(s)
- Sandrine Valade
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
- * E-mail:
| | - Bérangère S. Joly
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Agnès Veyradier
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Jehane Fadlallah
- EA3518, Université de Paris, Paris, France
- Department of Clinical Immunology, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Lara Zafrani
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Virginie Lemiale
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Amélie Launois
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Alain Stepanian
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Lionel Galicier
- EA3518, Université de Paris, Paris, France
- Department of Clinical Immunology, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Claire Fieschi
- EA3518, Université de Paris, Paris, France
- Department of Clinical Immunology, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Adrien Mirouse
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Jean Jacques Tudesq
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Anne-Claire Lepretre
- Transfusion Department, Etablissement Français Du Sang, Hôpital Saint-Louis, Paris, France
| | - Elie Azoulay
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Michael Darmon
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Eric Mariotte
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
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Keenan C, Nichols KE, Albeituni S. Use of the JAK Inhibitor Ruxolitinib in the Treatment of Hemophagocytic Lymphohistiocytosis. Front Immunol 2021; 12:614704. [PMID: 33664745 PMCID: PMC7923355 DOI: 10.3389/fimmu.2021.614704] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome driven by overactive T cells and macrophages that abundantly secrete numerous pro-inflammatory cytokines, including interferon (IFN)-gamma, interleukin (IL)-1-beta, IL-2, IL-6, IL-10, IL-18, and tumor necrosis factor (TNF). The release of these and other cytokines underlies many of the clinical and pathologic manifestations of HLH, which if left untreated, can lead to multi-organ failure and death. The advent of etoposide-based regimens, such as the Histiocyte Society HLH-94 and HLH-2004 protocols, has substantially decreased the mortality associated with HLH. Nevertheless, the 5-year survival remains low at ~60%. To improve upon these results, studies have focused on the use of novel cytokine-directed therapies to dampen inflammation in HLH. Among the agents being tested is ruxolitinib, a potent inhibitor of the Janus Kinase (JAK) and Signal Transducer and Activation of Transcription (STAT) pathway, which functions downstream of many HLH-associated cytokines. Here, we review the basic biology of HLH, including the role of cytokines in disease pathogenesis, and discuss the use of ruxolitinib in the treatment of HLH.
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Affiliation(s)
- Camille Keenan
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sabrin Albeituni
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
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Kim JS, Lee JY, Yang JW, Lee KH, Effenberger M, Szpirt W, Kronbichler A, Shin JI. Immunopathogenesis and treatment of cytokine storm in COVID-19. Theranostics 2021; 11:316-329. [PMID: 33391477 PMCID: PMC7681075 DOI: 10.7150/thno.49713] [Citation(s) in RCA: 274] [Impact Index Per Article: 91.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/20/2020] [Indexed: 12/18/2022] Open
Abstract
Severe coronavirus disease 2019 (COVID-19) is characterized by systemic hyper-inflammation, acute respiratory distress syndrome, and multiple organ failure. Cytokine storm refers to a set of clinical conditions caused by excessive immune reactions and has been recognized as a leading cause of severe COVID-19. While comparisons have been made between COVID-19 cytokine storm and other kinds of cytokine storm such as hemophagocytic lymphohistiocytosis and cytokine release syndrome, the pathogenesis of cytokine storm has not been clearly elucidated yet. Recent studies have shown that impaired response of type-1 IFNs in early stage of COVID-19 infection played a major role in the development of cytokine storm, and various cytokines such as IL-6 and IL-1 were involved in severe COVID-19. Furthermore, many clinical evidences have indicated the importance of anti-inflammatory therapy in severe COVID-19. Several approaches are currently being used to treat the observed cytokine storm associated with COVID-19, and expectations are especially high for new cytokine-targeted therapies, such as tocilizumab, anakinra, and baricitinib. Although a number of studies have been conducted on anti-inflammatory treatments for severe COVID-19, no specific recommendations have been made on which drugs should be used for which patients and when. In this review, we provide an overview of cytokine storm in COVID-19 and treatments currently being used to address it. In addition, we discuss the potential therapeutic role of extracorporeal cytokine removal to treat the cytokine storm associated with COVID-19.
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Affiliation(s)
- Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Maria Effenberger
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University Innsbruck, Innsbruck, Austria
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
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Yin G, Man C, Liao S, Qiu H. The Prognosis Role of AST/ALT (De Ritis) Ratio in Patients with Adult Secondary Hemophagocytic Lymphohistiocytosis. Mediators Inflamm 2020; 2020:5719751. [PMID: 33376452 PMCID: PMC7738797 DOI: 10.1155/2020/5719751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/15/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Secondary hemophagocytic lymphohistiocytosis (sHLH) accompanied by liver involvement, characterized by hepatomegaly and increased liver enzymes, is usually associated with elevated mortality. However, the magnitude of these associations remains unknown. Our objective was to assess the associations of the aspartate transaminase/alanine transaminase (AST/ALT, De Ritis) ratio with overall survival among adult patients with sHLH. METHODS A retrospective analysis was performed on 289 patients aged 18-86 years with complete serum transaminase data at diagnosis of sHLH. Multivariate Cox regression analyses and restricted cubic splines were conducted to address the association between the De Ritis ratio and the risk of mortality. RESULTS The median De Ritis ratio for the entire study population was 1.34 (IQR: 0.84-2.29). After a median follow-up time of 60 (range 17-227.5) days, 205 deaths occurred. After fully adjusting for hepatomegaly, albumin, fibrinogen, EBV, ferritin, etiologies, and treatment strategies, the adjusted hazard ratios (HRs) with corresponding confidence intervals (CIs) of mortality for the 2 st tertile and 3 st tertile were 1.2 (0.8-1.7) and 1.6 (1.1-2.2), respectively (P < 0.01 for trends). Restricted cubic spline confirmed a linear association between the log2-transformed De Ritis ratio and the risk of mortality. Moreover, this trend persisted in subgroups with MHLH, hyperferrinaemia, sCD25 ≤ 20,000 ng/L, patients without EBV infection, and those received treatment. CONCLUSIONS The De Ritis ratio is a strong and independent predictor for overall survival in patients with sHLH. As a readily available biomarker in routine clinical practice, it is used to identify patients with sHLH with inferior overall survival.
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Affiliation(s)
- Guangli Yin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
| | - Changfeng Man
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
| | - Shengen Liao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China
| | - Hongxia Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing 210029, China
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An PJ, Zhu YZ, Yang LP. Biochemical indicators of coronavirus disease 2019 exacerbation and the clinical implications. Pharmacol Res 2020; 159:104946. [PMID: 32450346 PMCID: PMC7244444 DOI: 10.1016/j.phrs.2020.104946] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) has sparked a global pandemic, affecting more than 4 million people worldwide. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause acute lung injury (ALI) and even acute respiratory distress syndrome (ARDS); with a fatality of 7.0 %. Accumulating evidence suggested that the progression of COVID-19 is associated with lymphopenia and excessive inflammation, and a subset of severe cases might exhibit cytokine storm triggered by secondary hemophagocytic lymphohistiocytosis (sHLH). Furthermore, secondary bacterial infection may contribute to the exacerbation of COVID-19. We recommend using both IL-10 and IL-6 as the indicators of cytokine storm, and monitoring the elevation of procalcitonin (PCT) as an alert for initiating antibacterial agents. Understanding the dynamic progression of SARS-CoV-2 infection is crucial to determine an effective treatment strategy to reduce the rising mortality of this global pandemic.
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Affiliation(s)
- Peng-Jiao An
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Key Laboratory of Drug Clinical Risk and Personalized Medication Evaluation, Beijing 100730, China; Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Yi Zhun Zhu
- School of Pharmacy and State Key Laboratory for the Quality Research of Chinese Medicine, Macau University of Science and Technology, Macau, China
| | - Li-Ping Yang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Key Laboratory of Drug Clinical Risk and Personalized Medication Evaluation, Beijing 100730, China.
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32
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Jianguo L, Zhixuan Z, Rong L, Xiaodong S. Ruxolitinib in Alleviating the Cytokine Storm of Hemophagocytic Lymphohistiocytosis. Pediatrics 2020; 146:peds.2019-1301. [PMID: 32680878 DOI: 10.1542/peds.2019-1301] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2019] [Indexed: 11/24/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome classified into primary HLH and secondary HLH. Secondary HLH is always caused by autoimmune disease, infections, or cancer. The first-line therapy for secondary HLH is the HLH 2004 protocol, including dexamethasone, etoposide, and supportive therapy. However, up to 30% of patients, especially pediatric patients, remain unresponsive to first-line treatment, and the mortality rate reaches 50% in children with HLH. Furthermore, some children who have special conditions, such as an active virus infection, are not suitable for immunosuppressants treatment. Recently, several HLH-promoting cytokines have been identified, including interferon-γ, interleukin-2, and interleukin-6. Janus kinase 1 and 2 control the signaling of many cytokines, notably interferon-γ, interleukin-2, and interleukin-6. Janus kinase 1 and 2 inhibitors, such as ruxolitinib, have been successfully used to treat HLH in mice. Here, we report that a boy, diagnosed with HLH and high titer of hepatitis B virus-DNA copies, improved quickly, and the cytokine storm of HLH was alleviated after receiving ruxolitinib. Five days after ruxolitinib treatment, entecavir was introduced and serum titer results of hepatitis B virus-DNA returned negative. With 3 months of ruxolitinib treatment and following-up 1 year, the boy's situation maintained sustained remission. In this study, it is suggested that ruxolitinib might be a first-line drug, which could alleviate the cytokine storm of HLH. This treatment may be ushering in the age of glucocorticosteroid-free HLH treatment, which is particularly meaningful for children because it avoids the side effects of glucocorticosteroid.
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Affiliation(s)
- Li Jianguo
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Zhou Zhixuan
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Liu Rong
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Shi Xiaodong
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
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33
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Prognostic Value of Blood-Based Inflammatory Biomarkers in Secondary Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2020; 40:718-728. [DOI: 10.1007/s10875-020-00801-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
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34
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Valade S, Mariotte E, Azoulay E. Coagulation Disorders in Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome. Crit Care Clin 2020; 36:415-426. [PMID: 32172822 DOI: 10.1016/j.ccc.2019.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe condition that can lead patients to the intensive care unit. HLH diagnosis may be challenging, as it relies on sets of aspecific criteria. Several organ dysfunctions have been described during HLH, including hemostasis impairment found in more than half of the patients. The most frequently reported anomaly is a decrease in the fibrinogen level, which has been associated with higher mortality rates. Coagulation impairment study in patients with HLH represents an interesting field of research, as little is known about the mechanism leading to hypofibrinogenemia.
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Affiliation(s)
- Sandrine Valade
- Medical ICU, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010 Paris, France.
| | - Eric Mariotte
- Medical ICU, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Elie Azoulay
- Medical ICU, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010 Paris, France
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35
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Prencipe G, Bracaglia C, Caiello I, Pascarella A, Francalanci P, Pardeo M, Meneghel A, Martini G, Rossi MN, Insalaco A, Marucci G, Nobili V, Spada M, Zulian F, De Benedetti F. The interferon-gamma pathway is selectively up-regulated in the liver of patients with secondary hemophagocytic lymphohistiocytosis. PLoS One 2019; 14:e0226043. [PMID: 31846457 PMCID: PMC6917341 DOI: 10.1371/journal.pone.0226043] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022] Open
Abstract
Aim of this study was to investigate the activation of the IFNγ pathway in the affected liver and in the blood of patients with secondary hemophagocytic lymphohistiocytosis (sHLH). To this purpose, the mRNA expression levels of IFNG and IFNγ-inducible genes as well as Tyrosine (701)-phosphorylated signal transducer and activator of transcription 1 (STAT1) protein levels were evaluated in the liver and in peripheral blood mononuclear cells (PBMCs) of three patients with sHLH with predominant liver involvement. The mRNA expression levels of IFNG and IFNγ-inducible genes were markedly higher in patient livers compared to control livers and to one disease control liver. Conversely, slight differences in the expression levels of Type I IFN-inducible genes and other classical inflammatory cytokine genes were found. Further supporting the activation of the IFNγ pathway, higher protein levels of phosphorylated and total STAT1 were detected in patient livers compared to control livers. When the expression of the same genes analysed in liver tissues was evaluated in PBMCs collected from 2 out of 3 patients before the liver biopsy, we found that mRNA levels of IFNγ-inducible genes were markedly increased. Accordingly, high circulating levels of IFNγ-inducible CXCL9 were observed in patients. Altogether, these data demonstrate the selective and marked up-regulation of the IFNγ pathway in the liver tissue and blood of patients with active sHLH. Finally, we show that measurement of circulating CXCL9 levels and evaluation of IFNγ-inducible gene expression levels in PBMCs may represent a new valid tool to better identify patients with suspected HLH with predominant liver involvement.
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Affiliation(s)
- Giusi Prencipe
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- * E-mail:
| | - Claudia Bracaglia
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonia Pascarella
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Giorgia Martini
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Marianna N. Rossi
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giulia Marucci
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Valerio Nobili
- Hepatology Gastroenterology and Nutrition Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Zulian
- Department of Woman and Child Health, University of Padua, Padua, Italy
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Tsujimoto H, Kounami S, Ichikawa T, Hama T, Suzuki H. Serum high mobility group box protein 1 (HMGB1) levels reflect clinical features of childhood hemophagocytic lymphohistiocytosis. J Blood Med 2019; 10:301-306. [PMID: 31695540 PMCID: PMC6717709 DOI: 10.2147/jbm.s216121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/13/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose Hemophagocytic lymphohistiocytosis (HLH) is a potentially lethal hyperinflammatory disorder. For further understanding of the pathogenesis of HLH, we examined serum levels of high mobility group box protein 1 (HMGB1) in children with HLH. Patients and methods Serum HMGB1 levels were measured in 28 patients with HLH and 6 normal controls using a quantitative enzyme-linked immunosorbent assay. The patients were 21 boys and 7 girls, aged from 10 days to 21 years, with a median age of 8.5 years. The underlying conditions of HLH were infection-associated HLH in 18 patients, malignancy-associated HLH in 7 patients, and genetic HLH in 3 patients. The relations between serum HMGB1 levels and clinical symptoms and laboratory parameters were analyzed. Results Serum HMGB1 levels were significantly higher in patients with HLH than in normal controls (median, 6.5 ng/mL, interquartile range, 4.25–13.1). The serial serum HMGB1 levels in one patient fell to reflect the disease activity. Serum HMGB1 levels were significantly higher in patients with disseminated intravascular coagulation (DIC) than in patients without DIC (p<0.001) and were also significantly higher in patients with central nervous system (CNS) complications than in patients without CNS complications (p<0.01). Serum HMGB1 levels were positively correlated with aspartate aminotransferase (rs =0.48, p<0.01, Spearman’s rank correlation coefficient) and negatively correlated with fibrinogen (rs = −0.475, p=0.011) and hemoglobin (rs = −0.465, p=0.013). Conclusion Serum HMGB1 levels reflect clinical features of childhood HLH. HMGB1 is a potential mediator involved in the pathogenesis and determining the clinical findings of HLH.
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Affiliation(s)
- Hiroshi Tsujimoto
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Shinji Kounami
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Takayuki Ichikawa
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Taketsugu Hama
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Hiroyuki Suzuki
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
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Merli P, Caruana I, De Vito R, Strocchio L, Weber G, Del Bufalo F, Buatois V, Montanari P, Cefalo MG, Pitisci A, Algeri M, Galaverna F, Quintarelli C, Cirillo V, Pagliara D, Ferlin W, Ballabio M, De Min C, Locatelli F. Role of interferon-γ in immune-mediated graft failure after allogeneic hematopoietic stem cell transplantation. Haematologica 2019; 104:2314-2323. [PMID: 30792213 PMCID: PMC6821635 DOI: 10.3324/haematol.2019.216101] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/18/2019] [Indexed: 12/26/2022] Open
Abstract
Pathophysiology of graft failure (GF) occurring after allogeneic hematopoietic stem cell transplantation (HSCT) still remains elusive. We measured serum levels of several different cytokines/chemokines in 15 children experiencing GF, comparing their values with those of 15 controls who had sustained donor cell engraftment. Already at day +3 after transplantation, patients developing GF had serum levels of interferon (IFN)-γ and CXCL9 (a chemokine specifically induced by IFNγ) significantly higher than those of controls (8859±7502 vs. 0 pg/mL, P=0.03, and 1514.0±773 vs. 233.6±50.1 pg/mlL, P=0.0006, respectively). The role played by IFNγ in HSCT-related GF was further supported by the observation that a rat anti-mouse IFNγ-neutralizing monoclonal antibody promotes donor cell engraftment in Ifngr1-/-mice receiving an allograft. In comparison to controls, analysis of bone marrow-infiltrating T lymphocytes in patients experiencing GF documented a predominance of effector memory CD8+ cells, which showed markers of activation (overexpression of CD95 and downregulation of CD127) and exhaustion (CD57, CD279, CD223 and CD366). Finally, we obtained successful donor engraftment in 2 out of 3 children with primary hemophagocytic lymphohistiocytosis who, after experiencing GF, were re-transplanted from the same HLA-haploidentical donor under the compassionate use coverage of emapalumab, an anti-IFNγ monoclonal antibody recently approved by the US Food and Drug Administration for treatment of patients with primary hemophagocytic lymphohistiocytosis. Altogether, these results suggest that the IFNγ pathway plays a major role in GF occurring after HSCT. Increased serum levels of IFNγ and CXCL9 represent potential biomarkers useful for early diagnosis of GF and provide the rationale for exploring the therapeutic/preventive role of targeted neutralization of IFNγ.
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Affiliation(s)
- Pietro Merli
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Ignazio Caruana
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Rita De Vito
- Bambino Gesù Children's Hospital, Department of Laboratories, Pathology Unit, Rome, Italy
| | - Luisa Strocchio
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Gerrit Weber
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Francesca Del Bufalo
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | | | | | - Maria Giuseppina Cefalo
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Angela Pitisci
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Mattia Algeri
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Federica Galaverna
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Concetta Quintarelli
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Valentina Cirillo
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | - Daria Pagliara
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
| | | | | | | | - Franco Locatelli
- Bambino Ges Children's Hospital, Department of Pediatric Hematology/Oncology, Cellular and Gene Therapy, Rome, Italy
- Department of Pediatrics, Sapienza, University of Rome, Rome, Italy
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38
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A wave of Foxp3 + regulatory T cell accumulation in the neonatal liver plays unique roles in maintaining self-tolerance. Cell Mol Immunol 2019; 17:507-518. [PMID: 31171863 DOI: 10.1038/s41423-019-0246-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022] Open
Abstract
Newborn animals require tightly regulated local and systemic immune environments to govern the development and maturation of multiple organs/tissues even though the immune system itself is far from mature during the neonatal period. Regulatory T cells (Tregs) are essential for maintaining immune tolerance/homeostasis and modulating inflammatory responses. The features of Tregs in the neonatal liver under steady-state conditions are not well understood. The present study aimed to investigate the phenotype, functions, and significance of neonatal Tregs in the liver. We found a wave of thymus-derived Treg influx into the liver during 1-2 weeks of age. Depletion of these Tregs between days 7 and 11 after birth rapidly resulted in Th1-type liver inflammation and metabolic disorder. More Tregs in the neonatal liver than in the spleen underwent MHC II-dependent activation and proliferation, and the liver Tregs acquired stronger suppressive functions. The transcriptomic profile of these neonatal liver Tregs showed elevated expression of PPARγ and T-bet and features of Tregs that utilize lipid metabolic machinery and are capable of regulating Th1 responses. The accumulation of Tregs with unique features in the neonatal liver is critical to ensure self-tolerance and liver maturation.
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Mechanisms of action of ruxolitinib in murine models of hemophagocytic lymphohistiocytosis. Blood 2019; 134:147-159. [PMID: 31015190 DOI: 10.1182/blood.2019000761] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/17/2019] [Indexed: 12/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an often-fatal disorder characterized by the overactivation of T cells and macrophages that excessively produce proinflammatory cytokines, including interferon-γ (IFN-γ). Previously, we reported that the JAK inhibitor ruxolitinib dampens T-cell activation and lessens inflammation in a model of HLH in which perforin-deficient (Prf1 -/-) mice are infected with lymphocytic choriomeningitis virus (LCMV). Ruxolitinib inhibits signaling downstream of IFN-γ, as well as several other JAK-dependent cytokines. As a consequence, it remained unclear whether ruxolitinib was exerting its beneficial effects in HLH by inhibiting IFN-γ signaling or by targeting signaling initiated by other proinflammatory cytokines. To address this question, we compared the effects of ruxolitinib with those obtained using an IFN-γ-neutralizing antibody (αIFN-γ) in 2 murine HLH models. In both models, ruxolitinib and αIFN-γ reduced inflammation-associated anemia, indicating that ruxolitinib operates in an IFN-γ-dependent manner to reverse this HLH manifestation. In contrast, the number and activation status of T cells and neutrophils, as well as their infiltration into tissues, were significantly reduced following treatment with ruxolitinib, but they remained unchanged or were increased following treatment with αIFN-γ. Notably, despite discontinuation of ruxolitinib, LCMV-infected Prf1 -/- mice exhibited enhanced survival compared with mice in which αIFN-γ was discontinued. This protective effect could be mimicked by transient treatment with αIFN-γ and a neutrophil-depleting antibody. Thus, ruxolitinib operates through IFN-γ-dependent and -independent mechanisms to dampen HLH by targeting the deleterious effects of T cells and neutrophils, with the latter representing an unappreciated and understudied cell type that contributes to HLH pathogenesis.
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Choi JE, Kwak Y, Huh JW, Yoo ES, Ryu KH, Sohn S, Hong YM. Differentiation between incomplete Kawasaki disease and secondary hemophagocytic lymphohistiocytosis following Kawasaki disease using N-terminal pro-brain natriuretic peptide. KOREAN JOURNAL OF PEDIATRICS 2018; 61:167-173. [PMID: 29853942 PMCID: PMC5976567 DOI: 10.3345/kjp.2018.61.5.167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 03/13/2018] [Accepted: 03/17/2018] [Indexed: 12/18/2022]
Abstract
Purpose Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome with many causes, including Kawasaki disease (KD). The purpose of this study was to identify the laboratory tests needed to easily differentiate KD with HLH from incomplete KD alone. Methods We performed a retrospective study on patients diagnosed with incomplete KD and incomplete KD with HLH (HLH-KD) between January 2012 and March 2015. We compared 8 secondary HLH patients who were first diagnosed with incomplete KD with all 247 incomplete KD diagnosed patients during the study period. The complete blood count, erythrocyte sedimentation rate, platelet count, and serum total protein, albumin, triglyceride, C-reactive protein, N-terminal pro-brain natriuretic peptide (NT-proBNP), and ferritin levels were compared. Clinical characteristics and echocardiography findings were also compared between the 2 groups. Results The total duration of fever was longer in the HLH-KD group than in the KD group. White blood cell and platelet counts were higher in the KD group. Alanine aminotransferase, ferritin, and coronary artery diameter were increased in the HLH-KD group compared with those in the KD group. The median of NT-proBNP was significantly higher in the HLH-KD group than in the KD group at 889.0 (interquartile range [IQR], 384.5-1792.0) pg/mL vs. 233.0 (IQR, 107.0-544.0) pg/mL. Conclusion The NT-proBNP level may be helpful in distinguishing incomplete KD from KD with HLH. The NT-proBNP level should be determined in KD patients with prolonged fever, in addition to the white blood cell count, platelet count, and ferritin level, to evaluate secondary HLH.
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Affiliation(s)
- Jung Eun Choi
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yujin Kwak
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jung Won Huh
- Department of Laboratory Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun-Sun Yoo
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Ha Ryu
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sejung Sohn
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Young Mi Hong
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
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Valade S, Canet E, Mariotte E. Syndrome d’activation macrophagique d’origine infectieuse : le point de vue du réanimateur. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le syndrome hémophagocytaire (SH) se présente classiquement sous la forme de cytopénies fébriles accompagnées d’un syndrome tumoral, le plus souvent dans le cadre d’un déficit immunitaire sous-jacent. Les formes les plus sévères s’accompagnent de défaillances d’organes qui peuvent conduire le patient en réanimation. Les principales étiologies de SH sont les infections, les hémopathies et les maladies de système. Les infections associées au SH sont majoritairement virales, liées à l’EBV, au CMV et aux autres virus du groupe herpes. Les infections bactériennes sont dominées par les mycobactéries, et les parasites sont essentiellement représentés par la leishmaniose et la toxoplasmose. Enfin, parmi les infections fongiques, l’histoplasmose est à rechercher en priorité. La prise en charge thérapeutique du SH associé aux infections comprend trois volets : le traitement de l’infection, les traitements de support et le traitement du SH. Les principaux traitements proposés dans le cadre du SH associé aux infections sont les corticoïdes, les immunoglobulines polyvalentes et l’étoposide. À la phase initiale, c’est principalement la gravité des patients (défaillances d’organes) qui guidera la décision d’administrer ou non un traitement spécifique du SH. Un aspect important de la prise en charge thérapeutique est la recherche systématique d’un déficit immunitaire sous-jacent, qui pourra faire l’objet d’une prise en charge spécifique. Le bilan minimal comprendra la recherche d’une infection par le VIH, la recherche d’une hémopathie lymphoïde sous-jacente (maladie de Hodgkin, lymphome non hodgkinien, maladie de Castleman) et la recherche d’arguments en faveur d’une maladie systémique (Lupus et maladie de Still).
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Vizcaino MA, Eberhart CG, Rodriguez FJ. Hemophagocytic Lymphohistiocytosis in Adults with Intraocular Involvement: Clinicopathologic Features of 3 Cases. Ocul Oncol Pathol 2018; 4:1-11. [PMID: 29344491 DOI: 10.1159/000475551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/30/2017] [Indexed: 01/15/2023] Open
Abstract
Background/Aims Hemophagocytic lymphohistiocytosis (HLH) is an infrequent inflammatory multisystemic syndrome. Only rare cases with ophthalmic involvement describing their pathologic features have been previously reported. Methods We report 3 cases of adult-onset HLH with bilateral ocular involvement and describe their clinicopathologic features. Results Three adult males - 2 with a history of viral infection - developed persistent fever, fatigue, bone marrow abnormalities, and irreversible multiorgan failure. Visual impairment was also documented in 2 cases. Complete autopsies were performed. Ophthalmic pathology demonstrated a bilateral histiocytic infiltrate with scant lymphocytes affecting the uvea. Focal extension to the retina, optic nerve, and trabecular meshwork were also identified, as well as hemophagocytosis in 1 case. Macrophages showed strong immunoreactivity for CD163 antibody and lacked BRAF p.V600E mutant protein. Conclusion HLH is an unusual disorder associated with several systemic conditions. Histologic features in the eye are poorly documented, with prior reports restricted to children. Our 3 adult cases are reported using updated criteria and, despite the difference in age, show changes similar to those observed in the pediatric population.
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Affiliation(s)
- M Adelita Vizcaino
- Division of Neuropathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Cellular and Tissue Biology, Faculty of Medicine, UNAM, Mexico City, Mexico
| | - Charles G Eberhart
- Division of Neuropathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fausto J Rodriguez
- Division of Neuropathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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A Case of Hemophagocytic Lymphohistiocytosis and Kawasaki Disease: Concurrent or Overlapping Diagnoses? J Pediatr Hematol Oncol 2018; 40:e32-e33. [PMID: 28452857 DOI: 10.1097/mph.0000000000000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is not always suspected at the time of presentation. It is often mistaken for other diagnoses; complicated by the fact that it is often associated with an inciting event that has significant overlap. Kawasaki disease, along with other disorders, such as Ebstein Barr Virus infection, are conditions that may lead HLH. Our patient had a presentation that was consistent with Kawasaki disease on initial presentation, however subsequently met the diagnostic criteria of HLH. It provided an interesting discussion about diagnoses with clinical criteria and how the overlap can sometimes delay or complicate initial diagnosis.
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Prognostic factors of early death in children with hemophagocytic lymphohistiocytosis. Cytokine 2017; 97:80-85. [PMID: 28582648 DOI: 10.1016/j.cyto.2017.03.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/10/2017] [Accepted: 03/31/2017] [Indexed: 11/20/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a rapidly progressing and fatal disease. Early identification of early death for HLH patients based on the laboratory findings at the time of diagnosis could improve the overall survival. A retrospective study was performed on 95 Chinese pediatric patients with HLH. Patients' data including clinical features and laboratory findings at diagnosis were collected. In a multivariate Cox proportional hazard regression model analysis, albumin≤27.75g/L (hazard ratio (HR)=11.82, 95% confidence interval (CI) 2.58-54.23; P=0.001), LDH≥3707.5 U/L (HR=4.15, 95%CI 1.43-12.01; P=0.009), and IL-10≥456pg/ml (HR=12.39, 95%CI 1.59-96.79; P=0.016) at diagnosis were independent prognostic factors of early death. The risk of early death was 33-fold increase in patients with three risk factors (HR=33.33; 95%CI 8.40-125.00; P<0.001), and 12-fold increase in patients with two risk factors (HR=12.80; 95%CI 2.34-69.80; P=0.002) when compared to it in patients with zero to one risk factor. Our results reveal that HLH patients with the risk of early death can be identified by laboratory findings at diagnosis, which may help guide the treatment decision making for this disease.
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Han XC, Ye Q, Zhang WY, Tang YM, Xu XJ, Zhang T. Cytokine profiles as novel diagnostic markers of Epstein-Barr virus–associated hemophagocytic lymphohistiocytosis in children. J Crit Care 2017; 39:72-77. [DOI: 10.1016/j.jcrc.2017.02.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/05/2017] [Indexed: 12/18/2022]
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Bordbar MR, Modarresi F, Farazi Fard MA, Dastsooz H, Shakib Azad N, Faghihi MA. A case report of novel mutation in PRF1 gene, which causes familial autosomal recessive hemophagocytic lymphohistiocytosis. BMC MEDICAL GENETICS 2017; 18:49. [PMID: 28468610 PMCID: PMC5415817 DOI: 10.1186/s12881-017-0404-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 04/08/2017] [Indexed: 11/21/2022]
Abstract
Background Hemophagocytic Lymphohistiocytosis (HLH) is a life-threatening immunodeficiency and multi-organ disease that affects people of all ages and ethnic groups. Common symptoms and signs of this disease are high fever, hepatosplenomegaly, and cytopenias. Familial form of HLH disease, which is an autosomal recessive hematological disorder is due to disease-causing mutations in several genes essential for NK and T-cell granule-mediated cytotoxic function. For an effective cytotoxic response from cytotoxic T lymphocyte or NK cell encountering an infected cell or tumor cell, different processes are required, including trafficking, docking, priming, membrane fusion, and entry of cytotoxic granules into the target cell leading to apoptosis. Therefore, genes involved in these steps play important roles in the pathogenesis of HLH disease which include PRF1, UNC13D (MUNC13-4), STX11, and STXBP2 (MUNC18-2). Case presentation Here, we report a novel missense mutation in an 8-year-old boy suffered from hepatosplenomegaly, hepatitis, epilepsy and pancytopenia. The patient was born to a first-cousin parents with no previous documented disease in his parents. To identify mutated gene in the proband, Whole Exome Sequencing (WES) utilizing next generation sequencing was used on an Illumina HiSeq 2000 platform on DNA sample from the patient. Results showed a novel deleterious homozygous missense mutation in PRF1 gene (NM_001083116: exon3: c. 1120 T > G, p.W374G) in the patient and then using Sanger sequencing it was confirmed in the proband and his parents. Since his parents were heterozygous for the identified mutation, autosomal recessive pattern of inheritance was confirmed in the family. Conclusions Our study identified a rare new pathogenic missense mutation in PRF1 gene in patient with HLH disease and it is the first report of mutation in PRF1 in Iranian patients with this disease.
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Affiliation(s)
| | - Farzaneh Modarresi
- Center for Therapeutic Innovation, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1501 NW 10th Ave, BRB 508, Miami, FL, 33136, USA
| | | | - Hassan Dastsooz
- Comprehensive Medical Genetic Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nader Shakib Azad
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ali Faghihi
- Center for Therapeutic Innovation, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1501 NW 10th Ave, BRB 508, Miami, FL, 33136, USA.
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