1
|
Hauch H, Skrzypek S, Woessmann W, Lehmberg K, Ehl S, Speckmann C, Schneck E, Koerholz D, Jux C, Neuhäuser C. Tuberculosis-Associated HLH in an 8-Month-Old Infant: A Case Report and Review. Front Pediatr 2020; 8:556155. [PMID: 33194891 PMCID: PMC7661936 DOI: 10.3389/fped.2020.556155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/29/2020] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare immunological disease, which can be mistaken for sepsis easily. Among the infectious causes that may trigger secondary HLH, tuberculosis (TBC), a rather rare pathogen nowadays, is typical. To our knowledge, this is the first case report of an infant suffering from TBC-associated HLH-induced acute respiratory failure who was treated successfully using extracorporeal membrane oxygenation. An 8-month-old boy with fever (over the last 8 wk) and pancytopenia was transferred to our institution with acute respiratory failure and for extracorporeal membrane oxygenation therapy. Bone marrow biopsy revealed hemophagocytosis. Immunological work-up for familial HLH was negative. In a desperate search for the cause of secondary HLH, an interferon-gamma release assay for TBC returned positive. However, microscopy for acid-fast bacteria as well as polymerase chain reaction for TBC were initially negative. Despite this, the child was treated with tuberculostatic therapy. TBC was finally confirmed. The child remained on extracorporeal membrane oxygenation for 28 d. Further work-up showed typical lesions of disseminated TBC. The mother was identified as the source of TBC. The boy presents with mild sequelae (fine motor skills). In infants with suspected septicemia, TBC should be considered as differential diagnosis even if the results are initially negative.
Collapse
Affiliation(s)
- Holger Hauch
- Department of Pediatric Hematology and Oncology, University Children's Hospital of Giessen, Giessen, Germany
| | - Susanne Skrzypek
- Department of Pediatric Cardiology and Intensive Care, University Children's Hospital Giessen, Giessen, Germany
| | - Wilhelm Woessmann
- Division of Pediatric Stem Cell Transplantation, University Children's Hospital Hamburg, UKE, Hamburg, Germany
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation, University Children's Hospital Hamburg, UKE, Hamburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg, Germany.,Center of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Carsten Speckmann
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg, Germany.,Center of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology and Intensive Care Medicine, University Children's Hospital Giessen, Giessen, Germany
| | - Dieter Koerholz
- Department of Pediatric Hematology and Oncology, University Children's Hospital of Giessen, Giessen, Germany
| | - Christian Jux
- Department of Pediatric Cardiology and Intensive Care, University Children's Hospital Giessen, Giessen, Germany
| | - Christoph Neuhäuser
- Department of Pediatric Cardiology and Intensive Care, University Children's Hospital Giessen, Giessen, Germany
| |
Collapse
|
2
|
Ullah W, Hamid M, Grover H, Figueredo VM, Inayat F. Takotsubo cardiomyopathy secondary to haemophagocytic lymphohistiocytosis in HIV patients: a comprehensive review. BMJ Case Rep 2019; 12:12/4/e226599. [PMID: 31015233 DOI: 10.1136/bcr-2018-226599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is an immune dysregulation disorder with variable presentations and non-specific features making it extremely difficult to diagnose early in the clinical course. Here, we are presenting a case of a young man who presented in cardiogenic shock with findings of anterolateral wall ischaemia on ECG. Echocardiography findings were consistent with takotsubo cardiomyopathy (TCM). Cardiac catheterisation showed clean coronary arteries and pulmonary artery pressure measurements showed high output cardiac failure. After extensive workup, the patient was diagnosed with HLH. In spite of aggressive supportive and definitive therapy, he eventually died due to a complicated clinical course. We did a comprehensive literature review and found that this is the first reported case of HLH presenting as TCM as the initial clinical manifestation.
Collapse
Affiliation(s)
- Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Pennsylvania, USA
| | - Mohsin Hamid
- Internal Medicine, Abington Hospital - Jefferson Health, Pennsylvania, USA
| | - Harshwant Grover
- Internal Medicine, Abington Hospital - Jefferson Health, Pennsylvania, USA
| | | | - Faisal Inayat
- Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| |
Collapse
|
3
|
Madakshira MG, Bhardwaj S, Gupta K, Chander Y, Bhalla A. A fatal case of enterovirus infection with secondary hemophagocytosis-case report with review of literature. APMIS 2018; 126:877-882. [PMID: 30357959 DOI: 10.1111/apm.12892] [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: 08/01/2018] [Accepted: 09/25/2018] [Indexed: 11/28/2022]
Abstract
Enterovirus is a common viral infection, which can affect multiple organ systems with an array of clinical presentation such as meningitis, encephalitis, myocarditis, and disseminated infections. The illness is usually asymptomatic and self-limited but few cases can be severe and life-threatening especially when associated with hemophagocytosis. We discuss a fatal case of disseminated enterovirus infection and the histomorphological features of the infection.
Collapse
Affiliation(s)
- Manoj Gopal Madakshira
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunny Bhardwaj
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kirti Gupta
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh Chander
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
Tian H, Zhang Y, Shi Y, Li X, Sun Q, Liu L, Zhao D, Xu B. Epidemiological and aetiological characteristics of hand, foot, and mouth disease in Shijiazhuang City, Hebei province, China, 2009-2012. PLoS One 2017; 12:e0176604. [PMID: 28486500 PMCID: PMC5423607 DOI: 10.1371/journal.pone.0176604] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/13/2017] [Indexed: 12/18/2022] Open
Abstract
Large outbreaks of hand, foot, and mouth disease (HFMD) have repeatedly occurred in mainland of China since 2007. In this study, we investigated the epidemiological and aetiological characteristics of HFMD in Shijiazhuang City, one of the biggest northern cities of China. A total of 57,173 clinical HFMD cases, including 911 severe and 32 fatal cases, were reported in Shijiazhuang City during 2009–2012. The disease incidence peaked during March–July, with a small increase in the number of cases observed in November of each year. Seventeen potential HFMD-causing enterovirus serotypes were detected, with the most frequent serotypes being EV-A71 and CV-A16. CV-A10 was also a frequently detected causative serotype, and was associated with the second largest number of severe HFMD cases, following EV-A71. Phylogenetic analysis revealed that all EV-A71, CV-A16 and CV-A10 strains from Shijiazhuang City had co-evolved and co-circulated with those from other Chinese provinces. Our findings underscore the need for enhanced surveillance and molecular detection for HFMD, and suggest that EV-A71 vaccination may be an effective intervention strategy for HFMD prevention and vaccines against CV-A10 and CV-A16 are also urgently needed.
Collapse
Affiliation(s)
- Huifang Tian
- Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, People’s Republic of China
- * E-mail:
| | - Yong Zhang
- WHO WPRO Regional Polio Reference Laboratory and Key Laboratory for Medical Virology, National Health and Family Planning Commission of China; National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
| | - Yan Shi
- Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, People’s Republic of China
| | - Xiujuan Li
- Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, People’s Republic of China
| | - Qiang Sun
- WHO WPRO Regional Polio Reference Laboratory and Key Laboratory for Medical Virology, National Health and Family Planning Commission of China; National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
| | - Li Liu
- Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, People’s Republic of China
| | - Dong Zhao
- Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, People’s Republic of China
| | - Baohong Xu
- Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, People’s Republic of China
| |
Collapse
|
5
|
Kawamura Y, Miura H, Matsumoto Y, Uchida H, Kudo K, Hata T, Ito Y, Kimura H, Yoshikawa T. A case of Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis with severe cardiac complications. BMC Pediatr 2016; 16:172. [PMID: 27793118 PMCID: PMC5084419 DOI: 10.1186/s12887-016-0718-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 10/25/2016] [Indexed: 01/13/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life threatening hematological disorder associated with severe systemic inflammation caused by an uncontrolled and ineffective immune response resulting in cytokine storm. Epstein-Barr virus (EBV) is the most common infectious agent in patients with the viral-associated HLH. Limited numbers of cases with cardiac complication have been demonstrated in other viral-associated HLH patients. Herein, we report a pediatric case of severe EBV-associated HLH with cardiac complications. Case presentation A previously healthy 4-year-old Japanese female was admitted to a local hospital with a four day history of fever. Despite antibiotic treatment, her fever persisted to day 7 of the illness. Finally, the diagnosis of HLH was confirmed by fulfilling diagnostic criteria for HLH and pathological analysis of bone marrow aspiration. Real-time PCR detected a high copy number of EBV DNA in the peripheral blood mononuclear cells (PBMCs) at the time of hospital admission. During treatment according to HLH-2004 protocol, sudden cardiopulmonary arrest (CPA) occurred on day 30 of the illness and immediate resuscitation was successful. Acute myocarditis was considered the cause of the CPA. Although the treatment regimen was completed on day 88 of the illness, a remarkably high copy number of EBV DNA was still detected in her PBMCs. Based on our flow cytometric in situ hybridization analysis that revealed EBV infection of only B lymphocytes, we decided to administer rituximab to control the abnormal EBV infection. Afterwards the amount of EBV DNA decreased gradually to undetectable level on day 130 of the illness. Unfortunately, a coronary artery aneurysm was discovered at the left main coronary artery on day 180 of the illness. Finally, the patient was discharged from the hospital on day 203 of the illness without sequelae except for a coronary aneurysm. Conclusions In this case report, EBV-HLH was complicated with cardiac symptoms such as myocarditis and coronary artery aneurysm. Although remarkably high copy number of EBV DNA was detected in PBMCs after completion of the HLH-2004 protocol, rituximab treatment resulted in a dramatic decrease of EBV DNA to undetectable levels. Rituximab treatment might have been beneficial for the patient’s survival.
Collapse
Affiliation(s)
- Yoshiki Kawamura
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan. .,Present address: Division of Viral Products, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA.
| | - Hiroki Miura
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan
| | - Yuji Matsumoto
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan
| | - Hidetoshi Uchida
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan
| | - Tadayoshi Hata
- Faculty of Medical Technology, School of Health Science, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroshi Kimura
- Department of Virology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan
| |
Collapse
|
6
|
Imashuku S. Hemophagocytic lymphohistiocytosis: Recent progress in the pathogenesis, diagnosis and treatment. World J Hematol 2014; 3:71-84. [DOI: 10.5315/wjh.v3.i3.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome that develops as a primary (familial/hereditary) or secondary (non-familial/hereditary) disease characterized in the majority of the cases by hereditary or acquired impaired cytotoxic T-cell (CTL) and natural killer responses. The molecular mechanisms underlying impaired immune homeostasis have been clarified, particularly for primary diseases. Familial HLH (familial hemophagocytic lymphohistiocytosis type 2-5, Chediak-Higashi syndrome, Griscelli syndrome type 2, Hermansky-Pudlak syndrome type 2) develops due to a defect in lytic granule exocytosis, impairment of (signaling lymphocytic activation molecule)-associated protein, which plays a key role in CTL activity [e.g., X-linked lymphoproliferative syndrome (XLP) 1], or impairment of X-linked inhibitor of apoptosis, a potent regulator of lymphocyte homeostasis (e.g., XLP2). The development of primary HLH is often triggered by infections, but not in all. Secondary HLH develops in association with infection, autoimmune diseases/rheumatological conditions and malignancy. The molecular mechanisms involved in secondary HLH cases remain unknown and the pathophysiology is not the same as primary HLH. For either primary or secondary HLH cases, immunosuppressive therapy should be given to control the hypercytokinemia with steroids, cyclosporine A, or intravenous immune globulin, and if primary HLH is diagnosed, immunochemotherapy with a regimen containing etoposide or anti-thymocyte globulin should be started. Thereafter, allogeneic hematopoietic stem-cell transplantation is recommended for primary HLH or secondary refractory disease (especially EBV-HLH).
Collapse
|
7
|
|
8
|
Fett JD. Diagnosis of viral cardiomyopathy by analysis of peripheral blood? Expert Opin Ther Targets 2008; 12:1073-5. [DOI: 10.1517/14728222.12.9.1073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Katsibardi K, Moschovi MA, Theodoridou M, Spanakis N, Kalabalikis P, Tsakris A, Tzortzatou-Stathopoulou F. Enterovirus-associated hemophagocytic syndrome in children with malignancy: report of three cases and review of the literature. Eur J Pediatr 2008; 167:97-102. [PMID: 17318619 DOI: 10.1007/s00431-007-0436-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 01/29/2007] [Accepted: 01/30/2007] [Indexed: 12/27/2022]
Abstract
Enteroviruses can cause severe manifestations in children with malignancy. Infection-associated hemophagocytic syndrome (IAHS) due to enterovirus is a rare entity in children. Patients with malignancy and IAHS due to enterovirus were retrospectively evaluated at the University of Athens' Hematology-Oncology pediatric unit within a 6-year period (2000-2006). IAHS occurred in three cases among 56 patients with documented enteroviral infection. The diagnosis of IAHS was confirmed by bone marrow aspiration and biopsy. Nested reverse transcriptase-polymerase chain reaction (RT-PCR), sequencing of the amplified alleles, and immunohistochemistry were performed to document the presence of enterovirus. The type of enterovirus was specified by indirect immunofluorescence assay. At the early phase of the disease, patients presented mild, non-specific viral symptoms, persistent unexplained fever, and pancytopenia. At the late phase, patients had more severe manifestations, such as persistent high fever, diarrhea, weight loss, hepatosplenomegaly, and hepatic dysfunction. The therapeutic approach consisted of supportive care, administration of immunoglobulin (400 mg/kg or 2 g/kg), and pleconaril. All patients had fatal outcome; two patients succumbed to multiorgan failure (MOF), while one patient succumbed to ventricular fibrillation. IAHS usually has fulminant course and leads to severe and life-threatening complications, such as liver failure and MOF. IAHS should always be included in the differential diagnosis of viral syndrome or unexplained fever. The therapeutic approach for IAHS should be administered as early as possible, before the progression to irreversible tissue damage. Early therapeutic intervention involving high doses of immunoglobulin might be beneficial for the patient's outcome.
Collapse
Affiliation(s)
- Katerina Katsibardi
- Hematology-Oncology Unit, First Department of Pediatrics, University of Athens, "Aghia Sophia" Children's Hospital, Thivon & Levadias Ave., Athens 11527, Greece
| | | | | | | | | | | | | |
Collapse
|