1
|
Wu L, Cao X, Wang J, Kong Q, Hu J, Shi L, Dou L, Song D, Chen L, Zhou M, Liu H, Ren R, Wang Z. Etiological stratification and prognostic assessment of haemophagocytic lymphohistiocytosis by machine learning on onco-mNGS data and clinical data. Front Immunol 2024; 15:1390298. [PMID: 39315095 PMCID: PMC11416948 DOI: 10.3389/fimmu.2024.1390298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 08/16/2024] [Indexed: 09/25/2024] Open
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a rare, complicated and life threatening hyperinflammatory syndrome that maybe triggered by various infectious agents, malignancies and rheumatologic disorders. Early diagnosis and identification of the cause is essential to initiate appropriate treatment and improve the quality of life and survival of patients. The recently developed Onco-mNGS technology can be successfully used for simultaneous detection of infections and tumors. Methods In the present study, 92 patients with clinically confirmed HLH were etiologically subtyped for infection, tumor and autoimmunity based on CNV and microbial data generated by Onco-mNGS technology, and a predictive model was developed and validated for the differential diagnosis of the underlying disease leading to secondary HLH. Furthermore, the treatment outcomes of patients with HLH triggered by EBV infection and non-EBV infection were evaluated, respectively. Results The current study demonstrated that the novel Onco-mNGS can identify the infection and malignancy- related triggers among patients with secondary HLH. A random forest classification model based on CNV profile, infectious pathogen spectrum and blood microbial community was developed to better identify the different HLH subtypes and determine the underlying triggers. The prognosis for treatment of HLH patients is not only associated with CNV, but also with the presence of pathogens and non- pathogens in peripheral blood. Higher CNV burden along with frequent deletions on chromosome 19, higher pathogen burden and lower non-pathogenic microbes were prognosis factors that significantly related with unfavorable treatment outcomes. Discussion Our study provided comprehensive knowledge in the triggers and prognostic predictors of patients with secondary HLH, which may help early diagnosis and appropriate targeted therapy, thus improving the survival and prognosis of the patients.
Collapse
Affiliation(s)
- Lin Wu
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xuefang Cao
- Research and Development (R&D) Department, MatriDx Biotechnology Co., Ltd., Hangzhou, China
| | - Jingshi Wang
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qi Kong
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Junxia Hu
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Shi
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liurui Dou
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Deli Song
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Leilei Chen
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Mengyuan Zhou
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huan Liu
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruotong Ren
- Research and Development (R&D) Department, EBV-Care Biotechnology Co., Ltd., Beijing, China
- Research and Development (R&D) Department, Micro-Health Biotechnology Co., Ltd., Beijing, China
- Foshan branch, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Zhao Wang
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Papazachariou A, Ioannou P. Hemophagocytic Lymphohistiocytosis Triggered by Herpes Simplex Virus 1 and 2: A Narrative Review. Hematol Rep 2024; 16:487-503. [PMID: 39189243 PMCID: PMC11348265 DOI: 10.3390/hematolrep16030047] [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: 05/09/2024] [Revised: 07/13/2024] [Accepted: 07/22/2024] [Indexed: 08/28/2024] Open
Abstract
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening syndrome characterized by an uncontrolled hyperinflammatory reaction. HLH is classified into primary (familial) and secondary (acquired). Secondary HLH is commonly triggered by infections, with viral infections being a leading cause. Its epidemiology and clinical features in cases associated with herpes simplex virus 1 and 2 remain underexplored. This study aimed to review all previously described cases of HSV-1 or -2-triggered HLH and provide information about this syndrome's epidemiology, microbiology, clinical characteristics, treatment, and outcomes. Methods: A narrative review was performed based on a search in PubMed, the Cochrane Library, and Scopus. Studies published until 27 April 2024 providing relevant data for HLH due to HSV 1 and 2 in humans were included. Results: We identified 29 eligible studies reporting HLH due to HSV 1 and 2, involving 34 patients. Half of them were adults, and half were neonates. Fever and splenomegaly were the most common clinical findings. Most patients were diagnosed with HSV-1 (64.7%), with PCR being the primary diagnostic method. The median duration of in-hospital treatment was 21 days, with acyclovir and steroids being the mainstays of therapy. The overall mortality rate was 41.2%, and AST levels emerged as an independent predictor of mortality. Conclusions: Our findings underscore the need for heightened awareness surrounding HLH triggered by HSV 1 and 2 and the importance of prompt diagnosis and tailored treatment approaches.
Collapse
Affiliation(s)
- Andria Papazachariou
- Department of Internal Medicine, University Hospital of Heraklion, 71500 Heraklion, Greece
| | - Petros Ioannou
- Department of Internal Medicine, University Hospital of Heraklion, 71500 Heraklion, Greece
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| |
Collapse
|
3
|
Alradhi SI, Almanjomi F, Alamr F, Alwakid I, Alrashidi M, Alkhelaif M. Clinical Presentations, Diagnosis, and Genetic Features of Hemophagocytic Lymphohistiocytosis: A Single Institutional Experience With the Saudi Population. Cureus 2024; 16:e61879. [PMID: 38978926 PMCID: PMC11228410 DOI: 10.7759/cureus.61879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal condition caused by high immune activation. The present study aimed to identify the clinical manifestations, geographic distribution, and associated pathogenic genetic mutations of HLH in Saudi Arabia. Method A retrospective cross-sectional study was conducted at King Fahad Medical City (KFMC), with a total of 59 patients diagnosed with HLH in the period between 2006 and 2018. All genetic results and clinical and biochemical data were retrieved and statistically analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). Results The results revealed that 48 patients (81.4%) had 15 pathogenic mutations of primary HLH whereas 8 (13.6%) patients had no genetic mutation. The most common variant mutation identified was c.1430C>T of the STXBP2 gene (42.4% of total patients), followed by c.1122G>A of the PRF1 gene (10.2% of patients), which demonstrated a distinctive geographic and tribal association. Patients with RAB27A mutation tend to present at an older age than the others with a median age of presentation of 5.5 months vs 2 months for patients with PRF1 mutations. No significant differences in clinical features were observed among the various groups. Conclusion This study highlights the incidence of genetic mutations among the Saudi population with HLH. The STXBP2 is the most common mutation followed by PRF1 mutations, many mutation variants are associated with a distinctive tribal and geographic association.
Collapse
Affiliation(s)
- Sami I Alradhi
- Pediatric Hematology and Oncology, Maternity and Children Hospital, Dammam, SAU
| | | | - Fahad Alamr
- College of Medicine, Al-Baha University, Al-Baha, SAU
| | | | | | | |
Collapse
|
4
|
Gopal A, Kim SJ. Hemophagocytic Lymphohistiocytosis in a Remote Kidney Transplant Recipient Triggered by HSV Infection With Complete Recovery: An Educational Case Report. Can J Kidney Health Dis 2024; 11:20543581241253921. [PMID: 38799982 PMCID: PMC11119350 DOI: 10.1177/20543581241253921] [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: 01/27/2024] [Accepted: 04/15/2024] [Indexed: 05/29/2024] Open
Abstract
Rationale Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by excessive immune activation. It is more commonly seen in children but increasingly recognized in adults. Primary HLH relies on a genetic predisposition, whereas secondary HLH develops in the context of infections, malignancies, or autoimmune diseases. Hemophagocytic lymphohistiocytosis has been rarely described in patients on immunosuppressive therapy after kidney transplant. Here, we describe a case of HLH in a patient with a remote history of kidney transplant, triggered by a viral infection. Presenting Concerns A 45-year-old female, with a kidney transplant in 2009 for IgA nephropathy, presented with fever, vomiting, and back pain of 1-week duration. She was on triple immunosuppression consisting of daily doses of prednisone 5 mg, azathioprine 100 mg, and tacrolimus extended release 1 mg, and a baseline creatinine of 130 µmol/L. Diagnosis Initial investigations showed anemia, leukopenia, elevated serum creatinine, transaminitis, and markedly increased ferritin of 67 600 µg/L which prompted a bone marrow biopsy to rule out HLH. The bone marrow showed an increased proportion of CD68+ cells (macrophages) with more than 5 in 1000 hemophagocytic macrophages. Her soluble IL-2 receptor (CD25) level was 3406 pg/mL (606-2299 pg/mL) which was mildly elevated. She fulfilled 4 of the 8 criteria for HLH and with an H score was 223 which suggested a diagnosis of HLH with 96.9% probability. An extensive secondary workup for possible triggers for HLH led to a swab from genital ulcers that was positive for herpes simplex virus (HSV) type 2. The polymerase chain reaction (PCR) in the blood for HSV type 2 was also positive. Interventions Given the diagnosis of HSV type 2 as the putative trigger for HLH, she was started on parenteral acyclovir for 2 weeks followed by oral valacyclovir for 2 more weeks. In the context of infection, the azathioprine was stopped while low-dose steroid and tacrolimus were continued. Outcomes With the initiation of treatment for HSV infection, leukopenia, creatinine, and transaminases improved along with ferritin levels. At her 6-month follow-up, her blood counts and liver enzymes had normalized, and ferritin was 566 µg/L. Teaching points Hemophagocytic lymphohistiocytosis is a rare disease in kidney transplant recipients with a high mortality rate. It can occur even in remote kidney transplant recipients so a high degree of suspicion is necessary to lead to a prompt diagnosis. Infections are common triggers for secondary HLH. Early identification and treatment of the triggering infection may improve outcomes.
Collapse
Affiliation(s)
- Anjana Gopal
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - S. Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| |
Collapse
|
5
|
Higuchi S, Lee S, Fujita K, Hara T, Tsurumi H. Filgrastim-induced hemophagocytic lymphohistiocytosis in a patient with mantle cell lymphoma: A case report. J Infect Chemother 2024; 30:150-153. [PMID: 37769993 DOI: 10.1016/j.jiac.2023.09.026] [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: 07/15/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease potentially induced by various causes. Very few reports have described HLH induced by granulocyte colony-stimulating factor (G-CSF) and those few previous reports have uniformly indicated that continuing G-CSF is unfeasible once HLH has been induced. A 52-year-old Japanese man who had been diagnosed with mantle cell lymphoma with systemic and central nervous system involvements received rituximab, hyper-fractionated cyclophosphamide, vincristine, Adriamycin and dexamethasone (R-HCVAD)/methotrexate and cytarabine. During the second cycle of R-HCVAD, the patient developed severe back pain, thrombocytopenia, elevated serum lactate dehydrogenase and ferritin levels, and hemophagocytosis in the bone marrow. Complete remission (CR) of mantle cell lymphoma was confirmed on whole-body computed tomography, brain magnetic resonance imaging, and bone marrow biopsy. The patient was diagnosed with HLH induced by filgrastim. HLH recovered with intravenous methylprednisolone at 1 g/day for 3 days, followed by oral prednisolone tapered off over 5 days. The patient continued chemotherapy with a change in the G-CSF formulation from filgrastim to lenograstim and prophylactic administration of corticosteroids. He safely completed scheduled chemotherapy without recurrence of HLH and successfully maintained CR of lymphoma. Although rare, G-CSF potentially induces HLH. Changing the G-CSF formulation and steroid prophylaxis may allow safe continuation of G-CSF.
Collapse
Affiliation(s)
- Sho Higuchi
- Department of Internal Medicine, Matsunami General Hospital, 185-1 Dendai, Kasamatsu-cho, Hashima-gun, Gifu, 501-6062, Japan.
| | - Shin Lee
- Department of Hematology and Oncology, Matsunami General Hospital, 185-1 Dendai, Kasamatsu-cho, Hashima-gun, Gifu, 501-6062, Japan.
| | - Kei Fujita
- Department of Hematology and Oncology, Matsunami General Hospital, 185-1 Dendai, Kasamatsu-cho, Hashima-gun, Gifu, 501-6062, Japan.
| | - Takeshi Hara
- Department of Hematology and Oncology, Matsunami General Hospital, 185-1 Dendai, Kasamatsu-cho, Hashima-gun, Gifu, 501-6062, Japan.
| | - Hisashi Tsurumi
- Department of Hematology and Oncology, Matsunami General Hospital, 185-1 Dendai, Kasamatsu-cho, Hashima-gun, Gifu, 501-6062, Japan.
| |
Collapse
|
6
|
Shimizu M. Clinical Features of Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:33-42. [PMID: 39117806 DOI: 10.1007/978-3-031-59815-9_4] [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
Cytokine storm syndrome (CSS) is a severe life-threatening condition characterized by a clinical phenotype of overwhelming systemic inflammation, hyperferritinemia, hemodynamic instability, and multiple organ failure (MOF), and, if untreated, it can potentially lead to death. The hallmark of CSS is an uncontrolled and dysfunctional immune response involving the continual activation and expansion of lymphocytes and macrophages, which secrete large amounts of cytokines, causing a cytokine storm. Many clinical features of CSS can be explained by the effects of pro-inflammatory cytokines, such as interferon (IFN)-γ, tumor necrosis factor (TNF), interleukin (IL)-1, IL-6, and IL-18 [1-7]. These cytokines are elevated in most patients with CSS as well as in animal models of CSS [8, 9]. A constellation of symptoms, signs, and laboratory abnormalities occurs that depends on the severity of the syndrome, the underlying predisposing conditions, and the triggering agent.
Collapse
Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| |
Collapse
|
7
|
Sterba G, Sterba Y. Parasitic and Fungal Triggers of Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:293-305. [PMID: 39117823 DOI: 10.1007/978-3-031-59815-9_21] [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
Infections caused by parasites and fungi can trigger the cytokine storm syndrome (CSS). These infections causing CSS can occur together with acquired immunodeficiencies, lymphomas, the use of immunosuppressive medications, transplant recipients, cancer, autoinflammatory, and autoimmune diseases or less frequently in healthy individuals. Histoplasma, Leishmania, Plasmodium, and Toxoplasma are the most frequent organisms associated with a CSS. It is very important to determine a previous travel history when evaluating a patient with a CSS triggered by these organisms as this may be the clue to the causal agent. Even though CSS is treated with specific therapies, an effort to find the causal organism should be carried out since the treatment of the infectious organism may stop the CSS. Diagnosing a CSS in the presence of parasitic or fungal sepsis should also lead to the study of an altered cytotoxic or hemophagocytic response in the susceptible host.
Collapse
|
8
|
Eloseily EM, Cron RQ. Bacteria-Associated Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:275-283. [PMID: 39117821 DOI: 10.1007/978-3-031-59815-9_19] [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
While viruses are considered the most common infectious triggers for cytokine storm syndromes (CSS), a growing list of bacterial pathogens, particularly intracellular organisms, have been frequently reported to be associated with this syndrome. Both familial and sporadic cases of CSS are often precipitated by acute infections. It is also important to note that an underlying precipitating infection might not be clinically obvious as the CSS clinical picture can mimic an infectious process or an overwhelming septicemia. It is important to detect such an underlying treatable condition. In addition, infections can also be acquired during the course of CSS due to the concurrent immune suppression with treatment. Optimal CSS outcomes require treating bacterial infections when recognized.CSS should always be suspected in patients presenting with a sepsis-like or multi-organ dysfunction picture. There are many criteria proposed to diagnose CSS in general, with HLH-2004 being the most commonly used. Alternatively, criteria have been proposed for CSS occurring in specific underlying conditions such as systemic lupus erythematosus (SLE) or systemic juvenile idiopathic arthritis (sJIA). However, waiting for many of these criteria to be fulfilled could lead to significant delay in diagnosis, and the physician needs a high index of suspicion for CSS in critically ill febrile hospitalized patients in order to properly recognize the condition. Thus, there should be diagnostic equipoise between CSS and infections, including bacterial, in this population. In this chapter, we discuss the more common bacterial precipitants of CSS with many of the cases being discussed in the pediatric age group.
Collapse
Affiliation(s)
| | - Randy Q Cron
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL, USA.
| |
Collapse
|
9
|
Chen QT, Chen MH, Lin YK, Yeh RH, Lu CC, Hsiao PJ, Sung YF. Case report: Hemophagocytic lymphohistiocytosis complicated by multiple organ dysfunction syndrome following aseptic encephalitis. Front Immunol 2023; 14:1296575. [PMID: 38193074 PMCID: PMC10773876 DOI: 10.3389/fimmu.2023.1296575] [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: 10/10/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially life-threatening condition caused by excessive immune activation. Secondary HLH is usually triggered by infection, most often from viral infection or malignancy. Here, we present a case of secondary HLH, complicated by multiple organ dysfunction syndrome triggered by critical aseptic encephalitis. A 27-year-old man without any underlying disease presented to our hospital with fever, disturbance of consciousness, and generalized seizures. The patient was diagnosed with aseptic encephalitis with super-refractory status epilepticus. Although antiseizure medications and immunoglobulins were administered, the patient developed multiple organ dysfunction syndrome. HLH was later diagnosed based on hypertriglyceridemia, hyperferritinemia, splenomegaly, cytopenia, and phagocytosis of nucleated cells, as shown by a blood smear of bone marrow aspiration. Treatment with pulse steroid therapy and plasmapheresis was initiated rather than chemotherapy because of the patient's critical condition. However, the patient died of profound shock and multiple organ failure. Diagnosis of HLH is challenging in patients with severe infections because of similar clinical manifestations and laboratory findings. The early recognition of HLH provides patients with the opportunity to receive appropriate treatment, which can lead to increased survival and remission rates.
Collapse
Affiliation(s)
- Quan-Ting Chen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Ming-Hua Chen
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yu-Kai Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ren-Hua Yeh
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Chi Lu
- Division of Rheumatology/Immunology and Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Hsiao
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yueh-Feng Sung
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| |
Collapse
|
10
|
Nakamura G, Matsuo S, Hosaka K, Abe T, Kato K, Yabe M, Murakami S, Hashidate H, Kondo D. Hemophagocytic Lymphohistiocytosis and Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis Possibly Caused by Enterococcus faecalis Infective Endocarditis. Intern Med 2023; 62:3691-3697. [PMID: 37121752 PMCID: PMC10781537 DOI: 10.2169/internalmedicine.1518-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/15/2023] [Indexed: 05/02/2023] Open
Abstract
Infection can induce hemophagocytic lymphohistiocytosis (HLH) and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We herein report a 52-year-old man who had HLH and AAV simultaneously, possibly caused by Enterococcus faecalis infective endocarditis. The HLH diagnosis was based on the HLH-2004 criteria. AAV was diagnosed based on a positive result for proteinase-3 ANCA and necrotizing vasculitis of the small vessels on a skin biopsy. He eventually died and was sent for autopsy after combination treatment of valve replacement, antibiotics, and immunosuppressants, including corticosteroids. This case involved a challenging diagnosis and treatment of HLH with various complications in an adult.
Collapse
Affiliation(s)
- Gen Nakamura
- Department of Nephrology and Rheumatology, Niigata City General Hospital, Japan
| | - Saki Matsuo
- Department of Nephrology and Rheumatology, Niigata City General Hospital, Japan
| | - Kiyoko Hosaka
- Department of Nephrology and Rheumatology, Niigata City General Hospital, Japan
| | - Takashi Abe
- Department of Hematology, Niigata City General Hospital, Japan
| | - Kaori Kato
- Department of Thoracic and Cardiovascular Surgery, Niigata City General Hospital, Japan
| | - Masahiro Yabe
- Department of General Internal Medicine, Niigata City General Hospital, Japan
| | - Shuichi Murakami
- Department of Nephrology and Rheumatology, Niigata City General Hospital, Japan
| | | | - Daisuke Kondo
- Department of Nephrology and Rheumatology, Niigata City General Hospital, Japan
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Fauchald T, Blomberg B, Reikvam H. Tuberculosis-Associated Hemophagocytic Lymphohistiocytosis: A Review of Current Literature. J Clin Med 2023; 12:5366. [PMID: 37629407 PMCID: PMC10455670 DOI: 10.3390/jcm12165366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a condition of immune dysregulation and hyperinflammation, leading to organ failure and death. Malignancy, autoimmune conditions, and infections, including Mycobacterium tuberculosis (TB), are all considered triggers of HLH. The aim of this study was to review all reported cases of TB-associated HLH in English literature, and to summarize the epidemiology, diagnostics, treatment, and mortality in patients with concomitant HLH and TB. A systematic review of described cases with TB-associated HLH, via a structured literature search in the medical database PubMed, is presented. Additional articles were included through cross-referencing with existing review articles. Articles were reviewed based on a predetermined set of criteria. A total of 116 patients with TB-associated HLH were identified with a male:female ratio of about 3:2. The age at presentation ranged from 12 days to 83 years. Malignancy, autoimmunity, and renal failure were the most common comorbid conditions. Most patients received both tuberculostatic and specific immunomodulating treatment, which was associated with a 66% (48/73) survival rate compared to 56% (15/27) in those receiving only tuberculostatic treatment, and 0% (0/13) in those receiving only immunomodulating treatment. The survival rate was 55% overall. The overlapping presentation between disseminated TB and HLH poses challenging diagnostics and may delay diagnosis and treatment, leading to increased mortality. TB should be considered as a potential trigger of HLH; clinicians' knowledge and awareness of this may result in the appropriate investigations needed to ensure diagnosis and proper treatment.
Collapse
Affiliation(s)
- Trym Fauchald
- Faculty of Medicine, University of Bergen, 5007 Bergen, Norway;
| | - Bjørn Blomberg
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| |
Collapse
|
14
|
Ing SK, Lee GWC, Leong TS, Lee YH, Lau GYL, Yusof NN, Chang AKW, Wong KKY. Secondary hemophagocytic lymphohistiocytosis: an unusual complication in disseminated Mycobacterium tuberculosis. Clin Med (Lond) 2023; 23:414-416. [PMID: 38614658 PMCID: PMC10541036 DOI: 10.7861/clinmed.2023-0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Tuberculosis-associated hemophagocytic lymphohistiocytosis (TB-HLH) is a rare and life-threatening complication of tuberculosis infection. Early recognition and treatment of TB-HLH is crucial for improving outcomes. Treatment typically involves a combination of antituberculosis therapy and immunosuppressive therapy to control the immune system's overreaction. In this report, we present the case of a 53-year-old ambulance driver who was diagnosed with TB-HLH. His CT scan revealed splenic abscesses, hepatomegaly and bilateral lung consolidation. He subsequently developed multiorgan failure, including acute respiratory distress syndrome (ARDS), transaminitis and bone marrow dysfunction. The clinical course and simultaneous increase in serum ferritin raised the suspicion of HLH. His Hscore was 254, indicating a high probability of hemophagocytic syndrome. TB diagnosis was confirmed by positive endotracheal TB GeneXpert and bone marrow aspiration (BMA) which detected acid-fast bacilli organisms. The patient was promptly started on anti-TB, dexamethasone and IVIG. The patient responded well to treatment and made a full recovery without any lasting complications. This case highlights the importance of promptly recognising HLH and identifying the underlying cause. In critically ill patients, it is crucial not to delay HLH-specific treatment while working up for differential diagnosis.
Collapse
|
15
|
"A Dangerous Black Box:" Idiopathic Hemophagocytic Lymphohistiocytosis in Adult Patients-A Case Report and Review of the Literature. Case Rep Hematol 2022; 2022:5867129. [PMID: 36510501 PMCID: PMC9741541 DOI: 10.1155/2022/5867129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare potentially life-threatening condition characterized by aberrant inflammation that can be related to genetic or sporadic forms. In both forms, triggering factors may be involved. Early detection of the underlying cause is crucial for therapeutic decision, while early intervention might be associated with better outcomes. The largest descriptions in the literature on HLH refer to pediatric cases. Adolescents and adults may also be affected, but there is scarce evidence regarding their diagnosis and management. We describe here the case of a 68-year-old Swiss woman with HLH, in whom an extensive search for underlying causes was performed, but neither trigger nor pathogenic variant was found. An early intervention first with dexamethasone and later with cyclosporine was performed. The patient showed a favorable response and did not require further hospitalization; however, one year after diagnosis, it was not possible to suspend cyclosporine due to recurrence of laboratory inflammation signs by drug tapering. The occurrence of HLH idiopathic forms represents a challenge; failure to identify the underlying triggering cause generates uncertainty, endless diagnostic investigations, and consequently additional delays in the treatment. This manuscript addresses the difficulties on this issue.
Collapse
|
16
|
Yildiz H, Castanares-Zapatero D, d’Abadie P, Bailly S, Yombi JC. Hemophagocytic Lymphohistiocytosis in Adults: A Retrospective Study in a Belgian Teaching Hospital. Int J Gen Med 2022; 15:8111-8120. [PMID: 36389021 PMCID: PMC9653050 DOI: 10.2147/ijgm.s388880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease, which can be primary (due to genetic mutation) or secondary to malignancy, infection and rheumatologic diseases. Data concerning Belgian patients with adult HLH are lacking. Methods This retrospective study was performed in a teaching hospital in Belgium. All cases of adult HLH, from December 2010 to April 2022, were reviewed. Patients with more than five HLH-2004 criteria and/or HScore >80% were included in the study. The objective of our study was to describe clinical and biological characteristics of patients with HLH and attempt to look for variables associated with mortality. Results Fifty-two patients were included in the final analysis. Mean age (SD) of patients was 48 (18) years old, and 29 patients were of male gender (56%). The underlying diseases associated with HLH were malignancy (M-HLH) in 22 patients, infection related HLH in 20 patients, rheumatologic disease related HLH in 7 patients, idiopathic in 2 patients and secondary to pregnancy in 1 patient. Overall mortality, mortality at 30 days and 90 days were 24/52 (46%), 13/52 (25%) and 4/52 (10%), respectively. In univariate analysis, malignancy, male sex, age and disseminated intravascular coagulation (DIC) were associated with mortality (p < 0.05). In multivariate analysis, only age was significantly associated with mortality (odds ratio, 1.053; 95% confidence interval, 1.016–1.092; p 0.005). Conclusion In our study, the most frequent triggers were malignancy and infectious agent followed by rheumatologic disease. Risk factors for mortality were age, male sex, malignancy and DIC, but only age remained significant in multivariate analysis. Treatment guidelines are mainly based on pediatric patients, and it is important for physician to describe adult patients’ outcome to better understand this disease and adapt treatment.
Collapse
Affiliation(s)
- Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
- Correspondence: Halil Yildiz, Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, 10 Av Hippocrate, Bruxelles, 1200, Belgium, Email
| | | | - Philippe d’Abadie
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - Sarah Bailly
- Department of Hematology, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - Jean Cyr Yombi
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| |
Collapse
|
17
|
Elliott RP, Freeman BP, Meier JL, El-Herte R. Acute Cytomegalovirus Illness in an Immunocompetent Adult Causing Intravascular Hemolysis and Suspected Hemophagocytic Lymphohistiocytosis. Case Rep Infect Dis 2022; 2022:7949471. [PMID: 35847599 PMCID: PMC9286925 DOI: 10.1155/2022/7949471] [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: 02/14/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Primary cytomegalovirus (CMV) infection of the immunocompetent host usually produces little-to-no illness. Occasionally, the infection results in mononucleosis syndrome, protracted fever, hepatitis, tissue-invasive disease, or Guillain-Barré syndrome. Hemolytic anemia and hemophagocytic lymphohistiocytosis (HLH) are rare complications that have not been reported to co-occur. Having hemolytic anemia in conjunction with more common findings of fever and hepatitis complicates the diagnosis of HLH. Case Presentation. A 34-year-old male with previously good health presented with a prolonged febrile illness, jaundice, and anemia. An extensive work-up during hospitalization revealed intravascular hemolytic anemia, leukopenia, hepatosplenomegaly, and biopsy evidence of extensive lymphohistiocytic infiltration of the liver with microgranulomata and sinusoidal hemophagocytosis. Soluble CD25 level was mildly elevated at 1200.3 pg/mL and the HScore calculation (fever, bicytopenia, hepatosplenomegaly, aspartate aminotransaminase 99 IU/L, ferritin 1570 ng/mL, fibrinogen 488 mg/dL, and triglycerides 173 mg/dL) suggested a moderate probability of reactive HLH. Primary CMV infection was diagnosed based on CMV IgM positivity, low CMV IgG avidity index, and low-grade CMV DNAemia. The CMV antigen was not detected in the liver biopsy, and the bone marrow biopsy was unremarkable. The illness began to improve before he received oral valganciclovir for 5 days, and he was in good health 10 months later. Conclusion Acute CMV illness in an immunocompetent adult can present with hemolytic anemia and clinicopathologic abnormalities consistent with a form fruste of HLH. The illness is likely due to an excessive or unbalanced immune response that may self-correct.
Collapse
Affiliation(s)
- Ross P. Elliott
- Internal Medicine Residency Program, MercyOne Medical Center and Clinics, Des Moines, IA 50314, USA
| | | | - Jeffery L. Meier
- Iowa City Veterans Affairs Health Care System, Iowa City, IA 52246, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Rima El-Herte
- Division of Infectious Diseases, Department of Medicine, Creighton, University School of Medicine and CHI Health, Omaha, NE 68124, USA
| |
Collapse
|
18
|
Lapuente JP, Gómez G, Marco-Brualla J, Fernández P, Desportes P, Sanz J, García-Gil M, Bermejo F, San Martín JV, Algaba A, De Gregorio JC, Lapuente D, De Gregorio A, Lapuente B, Gómez S, Andrés MDLV, Anel A. Evaluation in a Cytokine Storm Model in Vivo of the Safety and Efficacy of Intravenous Administration of PRS CK STORM (Standardized Conditioned Medium Obtained by Coculture of Monocytes and Mesenchymal Stromal Cells). Biomedicines 2022; 10:biomedicines10051094. [PMID: 35625831 PMCID: PMC9138962 DOI: 10.3390/biomedicines10051094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
Our research group has been developing a series of biological drugs produced by coculture techniques with M2-polarized macrophages with different primary tissue cells and/or mesenchymal stromal cells (MSC), generally from fat, to produce anti-inflammatory and anti-fibrotic effects, avoiding the overexpression of pro-inflammatory cytokines by the innate immune system at a given time. One of these products is the drug PRS CK STORM, a medium conditioned by allogenic M2-polarized macrophages, from coculture, with those macrophages M2 with MSC from fat, whose composition, in vitro safety, and efficacy we studied. In the present work, we publish the results obtained in terms of safety (pharmacodynamics and pharmacokinetics) and efficacy of the intravenous application of this biological drug in a murine model of cytokine storm associated with severe infectious processes, including those associated with COVID-19. The results demonstrate the safety and high efficacy of PRS CK STORM as an intravenous drug to prevent and treat the cytokine storm associated with infectious processes, including COVID-19.
Collapse
Affiliation(s)
- Juan Pedro Lapuente
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
- Correspondence: (J.P.L.); (A.A.)
| | - Gonzalo Gómez
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Joaquín Marco-Brualla
- Group Immunity, Cancer and Stem Cells, Faculty of Sciences, University of Zaragoza, 50009 Zaragoza, Spain;
| | - Pablo Fernández
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Paula Desportes
- GMP Facility, Peaches Biotech, 28050 Madrid, Spain; (P.D.); (J.S.)
| | - Jara Sanz
- GMP Facility, Peaches Biotech, 28050 Madrid, Spain; (P.D.); (J.S.)
| | | | - Fernando Bermejo
- Digestive Department, Fuenlabrada Hospital, 28942 Madrid, Spain;
- Medicine Department, University Rey Juan Carlos, 28942 Madrid, Spain
| | | | - Alicia Algaba
- Clinical Assay Department, Fuelabrada Hospital, 28942 Madrid, Spain;
| | - Juan Carlos De Gregorio
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Daniel Lapuente
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Almudena De Gregorio
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Belén Lapuente
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Sergio Gómez
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - María de las Viñas Andrés
- R4T Molecular and Cell Biology Research Laboratories, Fuenlabrada Hospital, 28942 Madrid, Spain; (G.G.); (P.F.); (J.C.D.G.); (D.L.); (A.D.G.); (B.L.); (S.G.); (M.d.l.V.A.)
| | - Alberto Anel
- Group Immunity, Cancer and Stem Cells, Faculty of Sciences, University of Zaragoza, 50009 Zaragoza, Spain;
- Correspondence: (J.P.L.); (A.A.)
| |
Collapse
|
19
|
Poornachandra, Wotiye AB, Ayele BA. Hemophagocytic lymphohistiocytosis: An unusual presentation of disseminated tuberculosis: A case report and literature review. J Clin Tuberc Other Mycobact Dis 2022; 27:100313. [PMID: 35372702 PMCID: PMC8971949 DOI: 10.1016/j.jctube.2022.100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome associated with cytokine storm. Here, we present a patient with acquired HLH associated with Mycobacterial tuberculosis infection. Case presentation We report a 66-year-old hypertensive and diabetic male patient who presented with four days history of fever and abdominal pain. Denied history of cough and weight loss. Laboratory investigation showed: elevated ferritin, C-reactive protein, and triglyceride. Bone marrow examination showed > 50% hemophagocytosis (RBCs and platelets ingested by macrophages), positive acid-fast bacillus for Mycobacterium tuberculosis bacilli, and no evidence of malignancy. Complete blood count showed anemia and thrombocytopenia. The patient fulfilled six out of eight clinical criterions of the acquired Hemophagocytic lymphohistiocytosis (HLH). The patient was managed with anti-tuberculous medications with adjuvant steroid. On the subsequent days, the patient showed significant clinical improvement and discharged home. However, the patient passed away a week after home discharge. Conclusion The present case highlights on the importance of early diagnosis and treatment of acquired HLH associated with tuberculous infection to improve the clinical outcome of the patient.
Collapse
|
20
|
Ponnatt TS, Lilley CM, Mirza KM. Hemophagocytic Lymphohistiocytosis. Arch Pathol Lab Med 2021; 146:507-519. [PMID: 34347856 DOI: 10.5858/arpa.2020-0802-ra] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder of immune regulation that can eventually result in end-organ damage and death. HLH is characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages that can lead to a cytokine storm. The diagnosis of HLH is often challenging due to the diverse clinical manifestations and the presence of several diagnostic mimics. The prognosis is generally poor, warranting rapid diagnosis and aggressive management. OBJECTIVE.— To provide a comprehensive review of the pathogenesis, clinical features, diagnosis, and management of HLH. DATA SOURCES.— Peer-reviewed literature. CONCLUSIONS.— HLH is a condition where a complete understanding of the pathogenesis, early diagnosis, and proper management has an important role in determining patient outcome. Genetic mutations causing impairment in the function of cytotoxic T lymphocytes and natural killer cells have been identified as the root cause of familial HLH; however, the specific pathogenesis of acquired HLH is unclear. The HLH-2004 protocol used in the diagnosis of HLH was originally developed for the pediatric population. The HLH-2004 protocol still forms the basis of the diagnosis of HLH in adults, although its use in adults has not been formally validated yet. Treatment of HLH is primarily based on the HLH-94 protocol, which involves suppressing the inflammatory response, but the treatment needs to be modified in adults depending on the underlying cause and comorbidities.
Collapse
Affiliation(s)
- Tanya Sajan Ponnatt
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Cullen M Lilley
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Kamran M Mirza
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| |
Collapse
|
21
|
Kim YR, Kim DY. Current status of the diagnosis and treatment of hemophagocytic lymphohistiocytosis in adults. Blood Res 2021; 56:S17-S25. [PMID: 33935031 PMCID: PMC8094004 DOI: 10.5045/br.2021.2020323] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of defective apoptosis, a disruption of the regulatory pathway that terminates immune and inflammatory responses. Fever, cytopenia, splenomegaly, and/or hemophagocytosis are typical findings of this syndrome. HLH can be induced by genetic disorders (familial) or secondary causes. Familial HLH is rare, while secondary causes in adults include infection, autoimmunity, and malignancy. HLH in adults tends to be confused with or misdiagnosed as sepsis, mainly due to similar clinical manifestations and laboratory findings, which make it difficult to diagnose HLH rapidly and adopt immunosuppressive agents and/or chemotherapy adequately. Treatment of pediatric HLH using HLH-2004 or multi-agent chemotherapy can be applied in adult patients, although the dose and type of drug need to be adjusted. It is highly recommended that allogenic hematopoietic stem cell transplantation should be used in patients who become reactivated or are refractory to the initial treatment as soon as possible to improve survival. Future clinical trials are warranted to determine more suitable treatments for adult patients with HLH.
Collapse
Affiliation(s)
- Yu Ri Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| |
Collapse
|
22
|
Hakamifard A, Mardani M, Gholipur‐Shahraki T. Hemophagocytic lymphohistiocytosis presented with fever of unknown origin: A case study and literature review. Clin Case Rep 2021; 9:2350-2355. [PMID: 33936693 PMCID: PMC8077318 DOI: 10.1002/ccr3.4033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/06/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening clinical syndrome, which may present with FUO. The possible diagnosis of HLH must be considered in the differential diagnosis when a patient presents with FUO.
Collapse
Affiliation(s)
- Atousa Hakamifard
- Infectious Diseases and Tropical Medicine Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Infectious DiseasesSchool of MedicineIsfahan University of Medical SciencesIsfahanIran
| | - Masoud Mardani
- Infectious Diseases and Tropical Medicine Research CenterShahid Beheshti University of Medical SciencesTehranIran
| | - Tahereh Gholipur‐Shahraki
- Department of Clinical Pharmacy and Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesIsfahan University of Medical SciencesIsfahanIran
| |
Collapse
|
23
|
Smits BM, van Montfrans J, Merrill SA, van de Corput L, van Gijn M, de Vries A, van den Bos C, Abbink F, van der Molen RG, Dors N, Lindemans C, Boelens JJ, Nierkens S. A Minimal Parameter Set Facilitating Early Decision-making in the Diagnosis of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2021; 41:1219-1228. [PMID: 33779897 PMCID: PMC8310853 DOI: 10.1007/s10875-021-01005-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 02/23/2021] [Indexed: 12/11/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune dysregulation syndrome characterized by uncontrolled immune cell activation. Timely diagnosis is important, since early treatment can improve survival rates. However, completing all assessments needed to reach ≥5 positive criteria out of the 8 HLH-2004 criteria can be time consuming and may delay timely initiation of treatment. Hence, we applied a data-driven approach to identify a minimal parameter set for early decision-making towards the initiation of HLH-specific treatment. We retrospectively evaluated 165 patients from five Dutch tertiary hospitals with suspected HLH. Sixteen pHLH (median age 0.5 years) and 70 sHLH patients (median age 8.7 years) were identified using the HLH-2004 criteria. Clustering analysis and multi-receiver operator characteristics were used to identify parameters distinctive of HLH. The presence of either increased ferritin, cytopenia in ≥2 lineages, or splenomegaly distinguished HLH from non-HLH cases with a negative predictive value of 100%. A minimal parameter set consisting of 2 major criteria (phagocytosis and splenomegaly) and 3 minor criteria (cytopenia, increased ferritin, and increased triglycerides/low fibrinogen) predicted HLH with 95% (88-99) sensitivity and 94% (86-98) specificity. This finding was replicated in an independent retrospective validation cohort of 109 US patients (n = 109). By dividing a subset of the HLH-2004 criteria into major and minor criteria, this strategy uses the evaluation of less than 5 criteria to quickly identify patients with HLH. When confirmed in a prospective setting, this approach could be of value for timely diagnosis and treatment of HLH.
Collapse
Affiliation(s)
- Bas M Smits
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Samuel A Merrill
- Division of Hematology/Oncology, West Virginia University, Morgantown, WV, USA
| | - Lisette van de Corput
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Mariëlle van Gijn
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrica de Vries
- Department of Pediatric Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Floor Abbink
- Department of Pediatric Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Renate G van der Molen
- Department of Laboratory Medicine, Laboratory for Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natasja Dors
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jaap J Boelens
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefan Nierkens
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands. .,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| |
Collapse
|
24
|
Chu R, van Eeden C, Suresh S, Sligl WI, Osman M, Cohen Tervaert JW. Do COVID-19 Infections Result in a Different Form of Secondary Hemophagocytic Lymphohistiocytosis. Int J Mol Sci 2021; 22:2967. [PMID: 33803997 PMCID: PMC8001312 DOI: 10.3390/ijms22062967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/12/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality across the world, with no current effective treatments available. Recent studies suggest the possibility of a cytokine storm associated with severe COVID-19, similar to the biochemical profile seen in hemophagocytic lymphohistiocytosis (HLH), raising the question of possible benefits that could be derived from targeted immunosuppression in severe COVID-19 patients. We reviewed the literature regarding the diagnosis and features of HLH, particularly secondary HLH, and aimed to identify gaps in the literature to truly clarify the existence of a COVID-19 associated HLH. Diagnostic criteria such as HScore or HLH-2004 may have suboptimal performance in identifying COVID-19 HLH-like presentations, and criteria such as soluble CD163, NK cell activity, or other novel biomarkers may be more useful in identifying this entity.
Collapse
Affiliation(s)
- Raymond Chu
- Division of Rheumatology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 7W9, Canada;
| | - Charmaine van Eeden
- Division of Rheumatology, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (C.v.E.); (M.O.)
| | - Sneha Suresh
- Division of IHOPE, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB T6G 1C9, Canada;
| | - Wendy I. Sligl
- Department of Critical Care Medicine and Division of Infectious Diseases, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2B7, Canada;
| | - Mohammed Osman
- Division of Rheumatology, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (C.v.E.); (M.O.)
| | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (C.v.E.); (M.O.)
| |
Collapse
|
25
|
Abou Shaar R, Eby CS, van Dorp S, de Witte T, Otrock ZK. Increasing ferritin predicts early death in adult hemophagocytic lymphohistiocytosis. Int J Lab Hematol 2021; 43:1024-1031. [PMID: 33595184 DOI: 10.1111/ijlh.13489] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/29/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome of pathologic immune activation. Most studies on adult HLH have evaluated prognostic factors for overall survival; factors predicting early mortality have not been sufficiently investigated. METHODS This was a collaborative study between Henry Ford Hospital and Barnes-Jewish Hospital. We identified all adult HLH patients with at least 2 ferritin levels within 30 days from admission. RESULTS One-hundred twenty-four patients were identified. There were 77 males and 47 females; the median age at diagnosis was 48 years. Multivariate analysis showed that age (OR = 11.41; 95% CI:2.71-48.04; P = .001), hepatomegaly (OR = 15.68; 95% CI:3.24-75.96; P = .001), hyponatremia (OR = 5.94; 95% CI:1.76-20.1; P = .004), hypoalbuminemia (OR = 7.47; 95% CI:2.08-26.85; P = .002), and increasing ferritin levels (OR = 19.46; 95% CI:4.69-80.71; P < .001) were significant predictors of 30-day mortality. Patients with declining ferritin by more than 35% from the ferritin peak were more likely to survive the first 30 days of admission (OR = 4.33; 95% CI:1.04-18.1; P = .033). By risk stratifying our cohort, we identified changes in ferritin levels to be the most significant prognostic factor of 30-day mortality among other risk factors. Further investigating the prognostic utility of ferritin showed that increasing ferritin during the 1st week of admission (data available for 44 patients) was the only significant predictor of 30-day mortality. CONCLUSIONS To the best of our knowledge, this is the first study reporting changes in ferritin to be a predictor for early death in adult HLH. Changes in ferritin might be a useful indicator of adult HLH disease activity and early prognosis.
Collapse
Affiliation(s)
- Rand Abou Shaar
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Charles S Eby
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Theo de Witte
- Radboud University Medical Center, Nijmegen, Netherlands
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA
| |
Collapse
|
26
|
Infection-associated Hemophagocytic Syndrome in Critically Ill Patients with COVID-19. Curr Med Sci 2021; 41:39-45. [PMID: 33582903 PMCID: PMC7881909 DOI: 10.1007/s11596-021-2315-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/29/2020] [Indexed: 01/28/2023]
Abstract
Infection-associated hemophagocytic syndrome (IAHS), a severe complication of various infections, is potentially fatal. This study aims to determine whether IAHS occurs in critically ill patients with coronavirus disease 2019 (COVID-19). We conducted a retrospective observational study on 268 critically ill patients with COVID-19 between February 1st, 2020 and February 26th, 2020. Demographics, clinical characteristics, laboratory results, information on concurrent treatments and outcomes were collected. A diagnosis of secondary hemophagocytic lymphohistiocytosis (sHLH) was made when the patients had an HScore greater than 169. Histopathological examinations were performed to confirm the presence of hemophagocytosis. Of 268 critically ill patients with confirmed SARS-CoV-2 infection, 17 (6.3%) patients had an HScore greater than 169. All the 17 patients with sHLH died. The interval from the onset of symptom of COVID-19 to the time of a diagnosis of sHLH made was 19 days and the interval from the diagnosis of sHLH to death was 4 days. Ten (59%) patients were infected with only SARS-CoV-2. Hemophagocytosis in the spleen and the liver, as well as lymphocyte infiltration in the liver on histopathological examinations, was found in 3 sHLH autopsy patients. Mortality in sHLH patients with COVID-19 is high. And SARS-CoV-2 is a potential trigger for sHLH. Prompt recognition of IAHS in critically ill patients with COVID-19 could be beneficial for improving clinical outcomes.
Collapse
|
27
|
Al Nasrallah N, Al-Hader A, Samala N, Sears CR. Hemophagocytic Lymphohistiocytosis in the Medical ICU: A Single-Institution Cohort Study on Acute Liver Failure and Mortality. Crit Care Explor 2021; 3:e0318. [PMID: 33458685 PMCID: PMC7803668 DOI: 10.1097/cce.0000000000000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory disorder that is associated with high morbidity and mortality in the ICU. It has also been associated with acute liver failure. DESIGN Retrospective observational study. SETTING Tertiary-care medical ICU. PATIENTS Thirty-one patients critically ill with hemophagocytic lymphohistiocytosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed a comprehensive review of critically ill hemophagocytic lymphohistiocytosis patients admitted to a tertiary-care medical ICU from January 2012 to December 2018. Most patients presented with constitutional symptoms and elevated liver enzymes and thrombocytopenia were common upon hospital admission. ICU admission laboratory and clinical variables were used to calculate Acute Physiology and Chronic Health Evaluation II, hemophagocytic syndrome diagnostic score, and model for end-stage liver disease. Mean age of the cohort was 48.1 years, and 45% were male. The mortality rate was 65% at 28 days and 77% at 1 year. About 28-day survivors were younger, had lower mean Acute Physiology and Chronic Health Evaluation II score (16.5 vs 23.0; p = 0.004), and higher mean hemophagocytic syndrome diagnostic score (249.1 vs 226.0; p = 0.032) compared with nonsurvivors. Survivors were less likely to receive mechanical ventilation, renal replacement therapy, or vasopressor support and were more likely to receive chemotherapy for hemophagocytic lymphohistiocytosis. In this ICU cohort, 29% were diagnosed with acute liver failure, of whom only 22% developed acute liver failure early during their hospital stay. Acute liver failure was associated with a higher model for end-stage liver disease score upon hospital admission. Available histology in those that developed acute liver failure showed massive hepatic necrosis, or histiocytic or lymphocytic infiltrates. CONCLUSIONS Patients admitted to the ICU with hemophagocytic lymphohistiocytosis have a high mortality. Those who survived had lower Acute Physiology and Chronic Health Evaluation scores, had higher hemophagocytic syndrome diagnostic scores, are more likely to receive hemophagocytic lymphohistiocytosis specific chemotherapy, and are less likely to have organ failure. Hemophagocytic lymphohistiocytosis can be associated with acute liver failure especially when model for end-stage liver disease score is elevated upon admission.
Collapse
Affiliation(s)
- Nawar Al Nasrallah
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Ahmad Al-Hader
- Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Niharika Samala
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN
| | - Catherine R Sears
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
- Division of Pulmonary Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| |
Collapse
|
28
|
Trovik LH, Sandnes M, Blomberg B, Holmaas G, Ahmed AB, Tvedt THA, Vintermyr O, Reikvam H. Hemophagocytic lymphohistiocytosis and miliary tuberculosis in a previously healthy individual: a case report. J Med Case Rep 2020; 14:217. [PMID: 33172493 PMCID: PMC7655140 DOI: 10.1186/s13256-020-02555-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/11/2020] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare heterogenous genetic or acquired hyperinflammatory syndrome associated with a high degree of morbidity and mortality. HLH has clinical manifestations related to abnormal prolonged activation of T lymphocytes and macrophages with an excess of proinflammatory cytokines. The main causes of secondary HLH are malignancies and infectious diseases. CASE PRESENTATION The patient was a 54-year-old man, originally from Eastern Africa, who had lived in Northern Europe for 30 years. Here we describe the clinical features, laboratory parameters, diagnostic workup, management and outcome data of a previously healthy 54-year-old man diagnosed with HLH secondary to tuberculosis. The patient was initially treated for a community-acquired pneumonia. He developed multiorgan failure with acute respiratory distress syndrome, hypertransaminasemia, and kidney and bone marrow dysfunction. The clinical course together with a simultaneous increase in serum ferritin raised the suspicion of HLH. The patient fulfilled seven out of eight diagnostic criteria for HLH. A thorough diagnostic workup with respect to HLH and a potential underlying disease was initiated. Cultivation of bronchoalveolar lavage fluid, stool and urine, and polymerase chain reaction of epithelioid cell granulomas in the bone marrow were all positive for Mycobacterium tuberculosis. He was treated for both HLH and tuberculosis, and he survived without any sequelae. CONCLUSIONS We present one of few published cases of a patient who survived HLH triggered by miliary tuberculosis. The current case illustrates the need for awareness of these two diagnoses, and the timely initiation of specific and supportive treatment to reduce mortality.
Collapse
Affiliation(s)
| | - Miriam Sandnes
- Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Bjørn Blomberg
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Gunhild Holmaas
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
| | | | | | - Olav Vintermyr
- Department of Pathology, Haukeland University Hospital, Bergen, Norway.,Departemnt of Medical Science, University of Bergen, Bergen, Norway
| | - Håkon Reikvam
- Department of Medicine, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway.
| |
Collapse
|
29
|
Singh A, Chauhan A, Padole V, Chhabra D, Upneja R. The great masquerader: Hemophagocytic lymphohistiocytosis secondary to cytomegalovirus infection in an immunocompetent young man. J Family Med Prim Care 2020; 9:3762-3765. [PMID: 33102367 PMCID: PMC7567245 DOI: 10.4103/jfmpc.jfmpc_274_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/13/2020] [Accepted: 04/03/2020] [Indexed: 11/15/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, poorly recognized and underdiagnosed syndrome of excessive immune activation, which is rapidly fatal. HLH can occur as a familial or secondary disorder. Secondary HLH is most commonly associated with infections, malignancies, or autoimmune diseases. It primarily affects patients with a compromised immune system and rarely presents in immunocompetent individuals. Acute cytomegalovirus (CMV) associated HLH in the immunocompetent individual is extremely rare and only documented in five case reports till date. We, hereby, report a case of 18 years old young immunocompetent man who was diagnosed to have HLH secondary to CMV infection.
Collapse
Affiliation(s)
- Akanksha Singh
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Ajay Chauhan
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vaibhav Padole
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Devyani Chhabra
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Raghav Upneja
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| |
Collapse
|
30
|
Lorenz G, Moog P, Bachmann Q, La Rosée P, Schneider H, Schlegl M, Spinner C, Heemann U, Schmid RM, Algül H, Lahmer T, Huber W, Schmaderer C. Title: Cytokine release syndrome is not usually caused by secondary hemophagocytic lymphohistiocytosis in a cohort of 19 critically ill COVID-19 patients. Sci Rep 2020; 10:18277. [PMID: 33106497 PMCID: PMC7589537 DOI: 10.1038/s41598-020-75260-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/05/2020] [Indexed: 02/08/2023] Open
Abstract
Severe COVID-19 associated respiratory failure, poses the one challenge of our days. Assessment and treatment of COVID-19 associated hyperinflammation may be key to improve outcomes. It was speculated that in subgroups of patients secondary hemophagocytic lymphohistiocytosis (sHLH) or cytokine release syndrome (CRS) with features of macrophage activation syndrome might drive severe disease trajectories. If confirmed, profound immunosuppressive therapy would be a rationale treatment approach. Over a median observation period of 11 (IQR: 8; 16) days, 19 consecutive confirmed severe COVID-19-patients admitted to our intensive-care-unit were tested for presence of sHLH by two independent experts. HScores and 2004-HLH diagnostic criteria were assessed. Patients were grouped according to short-term clinical courses: discharge from ICU versus ongoing ARDS or death at time of analysis. The median HScore at admission was 157 (IQR: 98;180), without the key clinical triad of HLH, i.e. progressive cytopenia, persistent fever and organomegaly. Independent expert chart review revealed the absence of sHLH in all cases. No patient reached more than 3/6 of modified HLH 2004 criteria. Nevertheless, patients presented hyperinflammation with peripheral neutrophilic signatures (neutrophil/lymphocyte-ratio > 3.5). The latter best paralleled their short-term clinical courses, with declining relative neutrophil numbers prior to extubation (4.4, [IQR: 2.5;6.3]; n = 8) versus those with unfavourable courses (7.6, [IQR: 5.2;31], n = 9). Our study rules out virus induced sHLH as the leading cause of most severe-COVID-19 trajectories. Instead, an associated innate neutrophilic hyperinflammatory response or virus-associated-CRS appears dominant in patients with an unfavourable clinical course. Therapeutic implications are discussed.
Collapse
Affiliation(s)
- Georg Lorenz
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- School of Medicine, Klinikum rechts der Isar, Division of Rheumatology, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Philipp Moog
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- School of Medicine, Klinikum rechts der Isar, Division of Rheumatology, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Quirin Bachmann
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- School of Medicine, Klinikum rechts der Isar, Division of Rheumatology, Ismaninger Straße 22, 81675, Munich, Germany
| | - Paul La Rosée
- Clinic for Internal Medicine II, Schwarzwald-Baar Klinikum Villingen-Schwenningen, Klinikstr. 11, 78052, Villingen-Schwenningen, Germany
| | - Heike Schneider
- School of Medicine, Klinikum rechts der Isar, Department for Clinical Chemistry, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michaela Schlegl
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Spinner
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Uwe Heemann
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Roland M Schmid
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hana Algül
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Comprehensive Cancer Center Munich at the Klinikum rechts der Isar, Technische Universität München, 81675, Munich, Germany
| | - Tobias Lahmer
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Wolfgang Huber
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Schmaderer
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- German Center for Infectious Research (DZIF), Technische Universität München, 81675, Munich, Germany
| |
Collapse
|
31
|
Patil SM, Beck PP, Patel TP, Hunter MP, Johnson J, Acevedo BA, Roland W. Cytomegalovirus pneumonitis-induced secondary hemophagocytic lymphohistiocytosis and SIADH in an immunocompetent elderly male literature review. IDCases 2020; 22:e00972. [PMID: 33024698 PMCID: PMC7529624 DOI: 10.1016/j.idcr.2020.e00972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 01/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is also known as hemophagocytic syndrome. It is a lethal hematologic condition due to a dysregulated immune response which results in inappropriately activated macrophages damaging host tissues. Based on the etiology, HLH can be primary (genetic) or secondary (acquired). The most common cause of a secondary HLH is an infection. Viral infections are the most common cause of secondary HLH. Among the viral causes of secondary HLH, Epstein–Barr virus is the most common etiologic agent. Cytomegalovirus (CMV) is a common causative pathogen in the immunocompromised host but is rare in an immunocompetent adult. In infection- associated secondary HLH, treatment includes antimicrobial therapy. HLH carries a high mortality and morbidity rate as it is an underdiagnosed clinical condition. Successful early diagnosis allows for adequate time for curative therapy. Treatment for HLH includes chemotherapy, immunomodulators, and a hematopoietic stem-cell transplant. The 2004 diagnostic criteria set by the Histiocyte Society serves as a guide to make an earlier clinical diagnosis. A review of PubMed literature revealed only five reported cases of CMV-induced HLH. We describe the sixth case of CMV pneumonitis-induced HLH and syndrome of inappropriate antidiuretic hormone secretion in a 72-year-old White male. He was treated successfully with oral valganciclovir and corticosteroids.
Collapse
Affiliation(s)
- Sachin M Patil
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Infectious Diseases, USA
| | - Phillip Paul Beck
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Infectious Diseases, USA
| | - Tarang Pankaj Patel
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Pulmonary, Critical Care and Environmental Medicine, USA
| | - Michael P Hunter
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Pulmonary, Critical Care and Environmental Medicine, USA
| | - Jeremy Johnson
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Pulmonary, Critical Care and Environmental Medicine, USA
| | - Bran Andres Acevedo
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Infectious Diseases, USA
| | - William Roland
- University of Missouri Hospital and Clinic, 1 Hospital Dr, Columbia, MO 65212, USA.,Department of Medicine, Division of Infectious Diseases, USA
| |
Collapse
|
32
|
Song Y, Wang J, Wang Y, Wang Z. HLA-mismatched GPBSC infusion therapy in refractory Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis: an observational study from a single center. Stem Cell Res Ther 2020; 11:265. [PMID: 32611452 PMCID: PMC7329501 DOI: 10.1186/s13287-020-01779-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/24/2020] [Accepted: 06/18/2020] [Indexed: 11/22/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a severe or even fatal inflammatory state. Epstein–Barr virus (EBV) infection-associated HLH (EBV-HLH) is one of the most common secondary HLH and suffers a very poor prognosis. Allo-HSCT is often required for refractory EBV-HLH, but some patients still cannot proceed to the next allo-HSCT due to various factors. This study aimed to observe the efficacy of HLA-mismatched granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood stem cells (GPBSCs) infusion for refractory EBV-HLH. Methods A retrospective case-control study of refractory EBV-HLH patients with GPBSC infusion from HLA-mismatched donors after chemotherapy (as GPBSC group) and sole chemotherapy (as control group) was performed. Efficacy was evaluated 2 and 4 weeks and all patients were followed-up until March 1, 2018. Results There were 18 cases who accepted infusion between March 2016 and Sep 2017 and 19 were randomly selected from refractory EBV-HLH patients who underwent salvage therapy during the same period for the control group. In GPBSC group, WBC (p = 0.017), Fbg (p = 0.040), and ferritin (p = 0.039) improved significantly after treatment. The overall response rate was 66.7% (CR 22.2%, PR 44.4%). However, there are no significant differences in changes of WBC, HGB, PLT, TG, Fbg, Ferritin, AST, ALT, and T-bil between two groups. Only the Fbg level was recovered better in the GPBSC infusion group (p = 0.003). In the GPBSC group, EBV-DNA decreased significantly after 2 weeks (p = 0.001) and 4 weeks (p = 0.012) after treatment, and the effect of the decrease was significantly better than that of the chemotherapy alone group in 2 weeks but not 4 weeks (p2w = 0.011, p4w = 0.145). The median survival time in the infusion group was 20.4 weeks [95% CI 10.9, 29.9], and the median survival time in the control group was 10.8 weeks [95% CI 0–24.34]. In the short-term, the infusion group’s survival rate was better (2-month 88.89% vs. 52.63%, p = 0.008; 3-month 83.33% vs. 47.09%, p = 0.012), but there was no difference in OS (p = 0.287). Conclusions Infusing GPBSCs combined with chemotherapy is effective, especially in decreasing EBV-DNA, performs better than chemotherapy alone, and improves short-term survival rate. GPBSC infusion is suggested as a bridging treatment method to allo-HSCT.
Collapse
Affiliation(s)
- Yue Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China.
| |
Collapse
|
33
|
Chen TY, Hsu MH, Kuo HC, Sheen JM, Cheng MC, Lin YJ. Outcome analysis of pediatric hemophagocytic lymphohistiocytosis. J Formos Med Assoc 2020; 120:172-179. [PMID: 32307323 DOI: 10.1016/j.jfma.2020.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/18/2020] [Accepted: 03/29/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease associated with rapid clinical deterioration and the need for intensive care; therefore, it is essential to identify clinical parameters related to mortality and establish prognostic factors correlated with unfavorable outcome in high risk patients whose treatment may fail. METHODS Between January 2004 and December 2018, a total of 51 pediatric patients (less than 18 years old) who fulfilled the diagnostic criteria of HLH-2004 with documented results of bone marrow investigations at Kaohsiung Chang Gung Memorial Hospital were enrolled. The treatment protocol was based on hemophagocytic lymphohistiocytosis-94 (HLH-94) and HLH-2004. We retrospectively reviewed electronic medical records (EMR) including clinical features, length of intensive care unit (ICU) stay, serological tests, microscopic reports of bone marrow examination, and ultrasound examination reports at diagnosis to identify prognostic factors. The patients were divided into four groups based on etiology; these included infection associated hemophagocytic syndrome (IAHS), macrophage activation syndrome (MAS), malignancy associated hemophagocytic lymphohistiocytosis (MA-HLH), and idiopathic hemophagocytic lymphohistiocytosis (IHLH) to identify differences among the groups. RESULTS Out of 51 patients enrolled, 27 patients had IAHS, 12 MAS, 8 MA-HLH, and 4 IHLH. The median age at diagnosis was 7 years. The overall mortality rate was 15.7% (there was no mortality in the MA-HLH group); the mean length of ICU stay was 6 ± 20.8 days. Longer activated partial thromboplastin time (aPTT) (p = 0.007), lower sodium concentration (p = 0.0007), and higher creatinine (p = 0.032) and aspartate aminotransferase (AST) (p = 0.017) were significantly related to mortality. Multivariate Cox regression analysis demonstrated that aPTT (p = 0.045, HR = 1.03, 95% CI = 1.0-1.1) was an independent risk factor for mortality. The receiver operating characteristic (ROC) curve showed that aPTT longer than 44.35 s was the cutoff value predicting mortality, with a sensitivity and specificity of 72% and 66.7%, respectively. CONCLUSION MA-HLH had the lowest mortality rate, as most children died from the underlying malignant disease and not from HLH. Impaired liver and renal functions were related to mortality. Prolonged aPTT > 44.35 s is a strong predictive factor for mortality.
Collapse
Affiliation(s)
- Tsung-Yen Chen
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Department of Pediatrics, E-Da Hospital, I-Shou university, Kaohsiung, Taiwan, ROC
| | - Mei-Hsin Hsu
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Division of Neurology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Hsuan-Chang Kuo
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Adjunct Lecturers, Department of Nursing, Meiho University, Taiwan, ROC
| | - Jiunn-Ming Sheen
- Division of Hematology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ming-Chou Cheng
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ying-Jui Lin
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC.
| |
Collapse
|
34
|
Yildiz H, Van Den Neste E, Defour JP, Danse E, Yombi JC. Adult haemophagocytic lymphohistiocytosis: a Review. QJM 2020; 115:hcaa011. [PMID: 31943120 DOI: 10.1093/qjmed/hcaa011] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/30/2019] [Accepted: 12/21/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder characterized by hyperimmune response. The mortality is high despite progress being made in the diagnosis and treatment of the disease. AIM This review aimed to update knowledge on adult HLH pathophysiology, identifiy the numerous causes, and help clinicians make early diagnosis and initiate treatment. DESIGN AND METHODS Using Embase, we searched relevant articles published from January 1, 2010 to October 31, 2019, with the MESH term « hemophagocytic lymphohistiocytosis; macrophagic activation syndrome, adult ». RESULTS The mean age at presentation is about 50 years, with a male predominance. The most frequent disease associations are haematological diseases, viral or bacterial infections, and autoimmune diseases. The pathophysiologic mechanism is probably the combination of inherited genetic mutations and extrinsic triggers. The mortality rate is 26.5% to 74.8%. H-score is more efficient than HLH-2004 criteria to identify HLH, with diagnostic sensitivity and specificity 90% and 79%, respectively.18F-FDG PET/CT is potentially useful for detecting underlying disease and the extent of secondary HLH. Disease-specific treatment should be given as soon as possible. Treatment with corticosteroids combined or not with etoposide is the mainstay of treatment. Monoclonal antibodies and JAK pathway inhibitors show promise of being effective. CONCLUSION In adult HLH, infectious diseases, autoimmune disease and malignancy should be suspected so that disease-specific treatment can be given promptly. Treatment with corticosteroids combined or not with etoposide is the mainstay of treatment, but new therapies show promise of being effective.
Collapse
Affiliation(s)
- Halil Yildiz
- Department of Internal medicine and Infectious diseases, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - Eric Van Den Neste
- Department of Hematology, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - Jean Philippe Defour
- Department of laboratory and immunohematology, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - Etienne Danse
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - J C Yombi
- Department of Internal medicine and Infectious diseases, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| |
Collapse
|
35
|
Erdoğan S, Çakır D, Bozkurt T, Karakayalı B, Kalın S, Koç B, Sözeri B. Hemophagocytic Lymphohistiocytosis Related to Tuberculosis Disease. Indian J Crit Care Med 2020; 24:63-65. [PMID: 32148351 PMCID: PMC7050167 DOI: 10.5005/jp-journals-10071-23329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, albeit potentially fatal, condition in which fever, hepatosplenomegaly, and cytopenia predominate the clinical picture. Although it may be primary, it may also develop secondary to various etiologies. Herein, we aimed to report a patient who was diagnosed with pulmonary tuberculosis, developed fever and cytopenia during follow-up, and received immunomodulatory therapy together with antituberculosis therapy for the diagnosis of HLH. Sequencing of PRF1 showed heterozygous mutation. Although primary HLH has been detected in infants and children, genetic mutation of genes should be considered a differential diagnosis of HLH even in the adolescent. How to cite this article Erdoğan S, Çakır D, Bozkurt T, Karakayalı B, Kalın S, Koç B, et al. Hemophagocytic Lymphohistiocytosis Related to Tuberculosis Disease. Indian J Crit Care Med 2020;24(1):63-65.
Collapse
Affiliation(s)
- Seher Erdoğan
- Department of Pediatric Critical Care, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Deniz Çakır
- Department of Pediatric Infectious Disease, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Tuğçe Bozkurt
- Department of Pediatrics, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Burcu Karakayalı
- Department of Pediatrics, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Sevinç Kalın
- Department of Pediatric Radiology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Begüm Koç
- Department of Pediatric Hematology and Oncology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
36
|
Georgiadou S, Gatselis NK, Stefos A, Zachou K, Makaritsis K, Rigopoulou EI, Dalekos GN. Efficient management of secondary haemophagocytic lymphohistiocytosis with intravenous steroids and γ-immunoglobulin infusions. World J Clin Cases 2019; 7:3394-3406. [PMID: 31750324 PMCID: PMC6854401 DOI: 10.12998/wjcc.v7.i21.3394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/20/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Secondary haemophagocytic lymphohistiocytosis (sHLH) is a rare life-threatening condition mainly associated with underlying infections, malignancies, and autoimmune or immune-mediated diseases.
AIM To analyse all sHLH cases that were diagnosed and managed under real-world circumstances in our department focusing on the treatment schedule and the outcome.
METHODS Prospectively collected data from all adult patients fulfilling the criteria of sHLH who diagnosed and managed from January 1, 2010 to June 1, 2018, in our department of the tertiary care university hospital of Larissa, Greece, were analysed retrospectively (n = 80; 52% male; median age: 55 years). The electronic records and/or written charts of the patients were reviewed for the demographic characteristics, clinical manifestations, underlying causes of sHLH, laboratory parameters, treatment schedule and 30-d-mortality rate. Most of patients had received after consent intravenous γ-immunoglobulin (IVIG) for 5 d (total dose 2 g/kg) in combination with intravenous steroid pulses followed by gradual tapering of prednisolone.
RESULTS Seventy-five patients (94%) reported fever > 38.5 °C, 47 (59%) had liver or spleen enlargement and 76 (95%) had ferritin > 500 ng/mL including 20 (25%) having considerably high levels (> 10000 ng/mL). Anaemia and thrombocytopenia occurred in 72% and leucopoenia in 47% of them. Underlying infections were diagnosed in 59 patients (74%) as follows: leishmaniasis alone in 15/80 (18.9%), leishmaniasis concurrently with Coxiella Burnetti or non-Hodgkin lymphoma in 2/80 (2.5%), bacterial infections in 14/80 (17.5%) including one case with concurrent non-Hodgkin lymphoma, viral infections in 13/80 (16.3%), fungal infections in 2/80 (2.5%), infections by mycobacteria in 1/80 (1.3%) and unidentified pathogens in 12/80 (15%). Seventy-two patients (90%) had received combination treatment with IVIG and intravenous steroids. Overall, sHLH resolved in 76% of patients, 15% died within the first month but 82.5% of patients were still alive 6 mo after diagnosis. Univariate analysis showed older age, anaemia, thrombocytopenia, low fibrinogen, disseminated intravascular coagulation (DIC), and delay of diagnosis as factors that negatively affected remission. However, multivariate analysis showed low platelets and DIC as the only independent predictors of adverse outcome.
CONCLUSION sHLH still carries a remarkable morbidity and mortality. Underlying infections were the major cause and therefore, they should be thoroughly investigated in patients with sHLH. Early recognition and combination treatment with IVIG and corticosteroids seem an efficient treatment option with successful outcome in this life-threatening condition.
Collapse
Affiliation(s)
- Sarah Georgiadou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Aggelos Stefos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Konstantinos Makaritsis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Eirini I Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| |
Collapse
|
37
|
Liang J, Xu D, Sun C, Chen W, Cao H, Lin J. Hemophagocytic Lymphohistiocytosis: Prevalence, Risk Factors, Outcome, and Outcome-related Factors in Adult Idiopathic Inflammatory Myopathies. J Rheumatol 2019; 47:1532-1540. [PMID: 31575703 DOI: 10.3899/jrheum.190542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To clarify the prevalence, risk factors, outcome, and outcome-related factors of hemophagocytic lymphohistiocytosis (HLH) in patients with dermatomyositis (DM), polymyositis (PM), or clinically amyopathic dermatomyositis (CADM). METHODS Data of patients with DM, PM, or CADM who were admitted to the First Affiliated Hospital of Zhejiang University from February 2011 to February 2019 were retrospectively collected. Patients diagnosed with HLH constituted the case group. A 1:4 case-control study was performed to identify risk factors for HLH in patients with DM, PM, or CADM through comparison, univariate, and multivariate logistic regression analysis. Intragroup comparison was made among patients with HLH to identify factors influencing unfavorable short-term outcome. RESULTS HLH was a rare (4.2%) but fatal (77.8%) complication in patients with DM, PM, or CADM. The retrospective case-control study revealed that higher on-admission disease activity (p = 0.008), acute exacerbation of interstitial lung disease (AE-ILD, p = 0.002), and infection (p = 0.002) were risk factors for complication of HLH in patients with DM, PM, or CADM. The following intragroup comparison showed that higher on-admission disease activity (p = 0.035) and diagnosis of CADM (p = 0.039) might influence the short-term outcome of patients with HLH. However, no risk factor was identified after false discovery rate correction. CONCLUSION In this study, secondary HLH was a fatal complication, with higher on-admission disease activity, AE-ILD, and infection working as risk factors. The underlying role of infection and autoimmune abnormality in HLH in connective tissue disease was subsequently noted. Clinical factors influencing the short-term outcome of patients with secondary HLH require further study.
Collapse
Affiliation(s)
- Junyu Liang
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Danyi Xu
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Chuanyin Sun
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Weiqian Chen
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Heng Cao
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Jin Lin
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China.
| |
Collapse
|
38
|
Song Y, Wang Y, Wang Z. Requirement for etoposide in the initial treatment of Epstein‐Barr virus–associated haemophagocytic lymphohistiocytosis. Br J Haematol 2019; 186:717-723. [PMID: 31115044 DOI: 10.1111/bjh.15988] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/25/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Yue Song
- Department of Haematology Beijing Friendship Hospital Capital Medical University Beijing China
| | - Yini Wang
- Department of Haematology Beijing Friendship Hospital Capital Medical University Beijing China
| | - Zhao Wang
- Department of Haematology Beijing Friendship Hospital Capital Medical University Beijing China
| |
Collapse
|
39
|
Mallick B, Daniel P, Dutta U. Hepatitis A infection related haemophagocytic syndrome: a case report and systematic review. Trop Doct 2019; 49:234-238. [PMID: 30871416 DOI: 10.1177/0049475519834804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome of excessive inflammation and tissue destruction owing to abnormal immune activation. We report an unusual case of haemophagocytosis associated with hepatitis A virus (HAV) infection in a 21-year-old man. This was further complicated by haemolysis secondary to G-6-PD deficiency and fungal sepsis. Our patient was treated successfully with intravenous immunoglobulin (IVIg) and supportive care. A systematic review of all reported cases of HAV associated haemophagocytosis is presented.
Collapse
Affiliation(s)
| | - Philip Daniel
- 1 Senior Resident, Department of Gastroenterology, PGIMER, Chandigarh, India
| | - Usha Dutta
- 2 Professor, Department of Gastroenterology, PGIMER, Chandigarh, India
| |
Collapse
|
40
|
Liao YT, Ko PS, Lin YT. The first case of Klebsiella pneumoniae liver abscess with hemophagocytic lymphohistiocytosis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 52:363-364. [PMID: 30528335 DOI: 10.1016/j.jmii.2018.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/19/2018] [Accepted: 10/30/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Ying-Ting Liao
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Po-Shen Ko
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
| | - Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan; Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan.
| |
Collapse
|
41
|
Telles JP, de Andrade Perez M, Marcusso R, Correa K, Teixeira RFA, Tobias WM. Hemophagocytic syndrome in patients living with HIV: a retrospective study. Ann Hematol 2018; 98:67-72. [PMID: 30255313 DOI: 10.1007/s00277-018-3500-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/16/2018] [Indexed: 01/29/2023]
Abstract
Various infectious diseases can hyper-stimulate the immune system, causing hemophagocytic syndrome (HPS). Little is known regarding the accuracy of diagnostic criteria and epidemiological triggering factors in the acquired immunodeficiency syndrome (AIDS) setting. We investigated the major infectious disease triggers of HPS in patients living with human immunodeficiency virus (HIV)/AIDS and determined the accuracy of bone marrow aspiration (BMA). The inclusion criteria were (i) confirmed HIV diagnosis, (ii) bone marrow aspiration, and (iii) a minimum of four HPS criteria. Patients were further classified into those with four presumed HPS criteria, or ≥ 5 confirmed criteria. The disease triggers, accuracy of bone marrow aspiration, and prognosis markers were examined. Presumed HPS was observed in 15/36 patients (41%), and confirmed HPS in 58% (n = 21). The major etiological triggers were infection with Mycobacterium (34%), Cytomegalovirus (14%), Cryptococcus neoformans (11%), and hematological or tumoral disease (11%). BMA demonstrated 93% specificity on screening diagnosis (odds ratio [OR] 12.7, 95% confidence interval [CI] 1.4-115.1, P = 0.01). Ferritin > 5000 ng/mL correlated with probability of death in univariate analysis (OR 6.00, 95% CI 1.33-27.05, P = 0.02). Ferritin performance as test of death probability presented area under the curve as 0.74 (95% CI 0.56-0.91, P = 0.016). However, neither cluster of differentiation for lymphocyte count nor HIV viral load correlated with patient deaths. Mycobacterium spp. and Cytomegalovirus were the main factors triggering HPS, followed by Cryptococcus neoformans, and hematological and tumoral diseases. High ferritin levels were associated with increased death probability. High specificity was noted with BMA.
Collapse
Affiliation(s)
- João Paulo Telles
- Instituto de Infectologia Emílio Ribas, Av. Dr Arnaldo, 165, São Paulo, SP, 01246-900, Brazil.
| | | | - Rosa Marcusso
- Instituto de Infectologia Emílio Ribas, Av. Dr Arnaldo, 165, São Paulo, SP, 01246-900, Brazil
| | - Karina Correa
- Instituto de Infectologia Emílio Ribas, Av. Dr Arnaldo, 165, São Paulo, SP, 01246-900, Brazil
| | | | - Walter Moises Tobias
- Division of Hemathology in Universidade Federal de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
42
|
Lange AV, Kazi S, Chen W, Barnes A. Fatal case of macrophage activation syndrome (MAS) in a patient with dermatomyositis and cytomegalovirus (CMV) viraemia. BMJ Case Rep 2018; 2018:bcr-2018-225231. [PMID: 30061130 PMCID: PMC6067131 DOI: 10.1136/bcr-2018-225231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 12/17/2022] Open
Abstract
We describe a case of an adult with dermatomyositis (DM) who presents with a rash, high fevers, tachycardia and hypotension, initially concerning for an infectious aetiology or a DM flare. She was found to have cytomegalovirus viraemia which improved after starting valganciclovir. After extensive workup and lack of improvement with broad-spectrum antimicrobial therapy, intravenous immunoglobulin and steroids, the patient was diagnosed with macrophage activation syndrome after bone marrow biopsy and levels of soluble CD25 (soluble interleukin (IL)-2 receptor) and IL2 were obtained. Unfortunately, despite therapy with dexamethasone, anakinra and etoposide, the patient decompensated and the patient's family opted for comfort care. The patient subsequently expired in the intensive care unit.
Collapse
Affiliation(s)
| | - Salahuddin Kazi
- Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Weina Chen
- Pathology, Univ Texas SW Med Ctr Dallas, Dallas, Texas, USA
| | - Arti Barnes
- Infectious Diseases, University of Texas Southwestern, Dallas, Texas, USA
| |
Collapse
|
43
|
A Case of Spontaneously Improving Secondary Hemophagocytic Lymphohistiocytosis in an Adult Associated with T-Cell Histiocyte-Rich Large B-Cell Lymphoma. Case Rep Oncol Med 2018; 2018:8069182. [PMID: 29682376 PMCID: PMC5842713 DOI: 10.1155/2018/8069182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/05/2018] [Indexed: 11/29/2022] Open
Abstract
Secondary hemophagocytic lymphohistiocytosis (HLH) in adults is a rare, often fatal syndrome characterized by widespread immune dysregulation. It is seen as a complication of infections, autoimmune diseases, and malignancies. Among the malignancy-related causes, aggressive T-cell or NK-cell neoplasms are most notable, while B-cell lymphomas are less commonly implicated. We present the case of a 32-year-old male transferred to our facility with concern for HLH. During the first week of his hospitalization, his diagnosis was confirmed and the patient demonstrated spontaneous improvement in his symptoms prompting us to delay therapy while searching for a primary cause. In the second week, the patient deteriorated, leading us to initiate steroid monotherapy in the absence of a cause for his HLH. Meanwhile, pathology results from an excisional lymph node biopsy confirmed a diagnosis of T-cell/histiocyte-rich large B-cell lymphoma (TCHRLBCL). Subsequently, we initiated therapy with dose-adjusted R-EPOCH. The patient achieved a complete remission of both HLH and TCHRLBCL as well as a complete return to his prior functional status. In our review of the literature, this represents only the second documented case of HLH associated with TCHRLBCL and the only documented case of an adult experiencing significant spontaneous recovery in this context.
Collapse
|
44
|
Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
Collapse
Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | |
Collapse
|
45
|
Al-Samkari H, Berliner N. Hemophagocytic Lymphohistiocytosis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2017; 13:27-49. [PMID: 28934563 DOI: 10.1146/annurev-pathol-020117-043625] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening disorder characterized by unbridled activation of cytotoxic T lymphocytes, natural killer (NK) cells, and macrophages resulting in hypercytokinemia and immune-mediated injury of multiple organ systems. It is seen in both children and adults and is recognized as primary (driven by underlying genetic mutations that abolish critical proteins required for normal function of cytotoxic T cells and NK cells) or secondary (resulting from a malignant, infectious, or autoimmune stimulus without an identifiable underlying genetic trigger). Clinical and laboratory manifestations include fever, splenomegaly, neurologic dysfunction, coagulopathy, liver dysfunction, cytopenias, hypertriglyceridemia, hyperferritinemia, hemophagocytosis, and diminished NK cell activity. It is treated with immune suppressants, etoposide, and allogeneic hematopoietic stem cell transplantation; more than 50% of children who undergo transplant survive, but adults have quite poor outcomes even with aggressive management. Newer agents directed at subduing the uncontrolled immune response in a targeted fashion offer promise in this highly morbid disease.
Collapse
Affiliation(s)
| | - Nancy Berliner
- Brigham & Women's Hospital, Boston, Massachusetts 02115;
| |
Collapse
|
46
|
Ordaya EE, Jarir SA, Yoo R, Chandrasekar PH. Hemophagocytic lymphohistiocytosis (HLH): Elusive diagnosis of disseminated Mycobacterium avium complex infection. Germs 2017; 7:149-152. [PMID: 28932715 DOI: 10.18683/germs.2017.1120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/29/2017] [Accepted: 07/30/2017] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome of hyperinflammation leading to an uncontrolled and ineffective immune response, associated with high mortality. CASE REPORT A 26-year-old woman with acute lymphoblastic leukemia, 8 months in remission, was found to have HLH. Without any improvement, stem cell transplantation was considered. Then, Mycobacterium avium complex (MAC) infection was identified as cause of her HLH. With appropriate therapy for infection, HLH improved and transplantation was averted. CONCLUSION MAC should be included in the list of potential causes of HLH.
Collapse
Affiliation(s)
- Eloy E Ordaya
- MD, Division of Infectious Diseases, Henry Ford Hospital, PO Box 553920, 2799 W. Grand Blvd, Detroit, MI 48202-3920, USA
| | - Sulieman Abu Jarir
- MD, Hamad Medical Corporation, Hamad General Hospital, PO Box 3050, Al Rayyan Rd, Doha, Qatar
| | - Robert Yoo
- DO, Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201, USA
| | - Pranatharthi H Chandrasekar
- MD, Karmanos Cancer Institute, Detroit, Division of Infectious Diseases, Wayne State University School of Medicine/Harper University Hospital, 3990 John R, Detroit, MI 48201, USA
| |
Collapse
|
47
|
Daver N, McClain K, Allen CE, Parikh SA, Otrock Z, Rojas-Hernandez C, Blechacz B, Wang S, Minkov M, Jordan MB, La Rosée P, Kantarjian HM. A consensus review on malignancy-associated hemophagocytic lymphohistiocytosis in adults. Cancer 2017. [PMID: 28621800 DOI: 10.1002/cncr.30826] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation and dysregulation resulting in extreme and often life-threatening inflammation. HLH has been well recognized in pediatric populations, and most current diagnostic and therapeutic guidelines are based on pediatric HLH. Recently there has been recognition of HLH in adults, especially secondary to immune deregulation by an underlying rheumatologic, infectious, or malignant condition. This review is focused on malignancy-associated HLH (M-HLH), in which possible mechanisms of pathogenesis include severe inflammation, persistent antigen stimulation by the tumor cells, and loss of immune homeostasis because of chemotherapy, hematopoietic stem cell transplantation, or infection. Previously considered rare, M-HLH may occur in up to 1% of patients with hematologic malignancies. M-HLH is often missed or diagnosed late in most published studies, and it has been associated with a poor median survival of less than 2 months. Identification of the clinical and laboratory features specific to M-HLH in adults may allow early detection, consultation with HLH experts, and intervention. Improved management of adult M-HLH with optimal combinations of T-lympholytic and immunosuppressive agents and the incorporation of novel agents based on the pediatric experience hopefully will improve outcomes in adults with M-HLH. Cancer 2017;123:3229-40. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth McClain
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Carl E Allen
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | | | - Zaher Otrock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Boris Blechacz
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milen Minkov
- University Clinic of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael B Jordan
- Langerhans Cell Histiocytosis Center, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Paul La Rosée
- Department of Internal Medicine, Schwarzwald-Baar Clinic, Villingen-Schwenningen, Germany
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
48
|
Similar but not the same: Differential diagnosis of HLH and sepsis. Crit Rev Oncol Hematol 2017; 114:1-12. [PMID: 28477737 DOI: 10.1016/j.critrevonc.2017.03.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/12/2022] Open
Abstract
Differential diagnosis of hemophagocytic lymphohistiocytosis (HLH; hemophagocytic syndrome) and sepsis is critically important because the life-saving aggressive immunosuppressive treatment, required in the effective HLH therapy, is absent in sepsis guidelines. Moreover, HLH may be complicated by sepsis. Hyperinflammation, present in both states, gives an overlapping clinical picture including fever and performance status deterioration. The aim of this review is to provide aid in this challenging diagnostic process. Analysis of clinical features and laboratory results in multiple groups of patients (both adult and pediatric) with either HLH or sepsis allows to propose criteria differentiating these two conditions. The diagnosis of HLH is supported by hyperferritinemia, splenomegaly, marked cytopenias, hypofibrinogenemia, low CRP, characteristic cytokine profile and, only in adults, hypertriglyceridemia. In the presence of these parameters (especially the most characteristic hyperferritinemia), the other HLH criteria should be assessed. Genetic analyses can reveal familial HLH. Hemophagocytosis is neither specific nor sensitive for HLH.
Collapse
|
49
|
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) has well been studied as a genetic disorder in children (primary HLH). Mutations in the regulatory complex of the cellular immune synapse lead to a loss of function of cytotoxic T‑cells and natural killer cells with excessive inflammation based on a cytokine storm. During the last decade, an increasing number of adult HLH patients without a family history of HLH (secondary or acquired HLH) have been reported. Various triggers - infections, malignancies or autoimmune diseases - result in an acquired loss of function of these cells and a sepsis-like disease. Missed or late diagnosis is believed to be a major cause of the high mortality. OBJECTIVES To describe the current knowledge on HLH and to raise awareness. MATERIALS AND METHODS Analysis of case reports, current studies, and expert recommendations. RESULTS Increased vigilance in identifying the adult form of HLH resulted in an increasing number of case reports over the past few years. HLH patients typically present with a clinical phenotype resembling severe sepsis or septic shock with fever, cytopenia, and organomegaly, which do not or insufficiently respond to anti-infective treatment. Early recognition of HLH distinction from sepsis, and prompt initiation of treatment - which is fundamentally different from sepsis - are crucial for improved outcome. A promising diagnostic parameter is ferritin, which has gained sufficient specificity, but only in the context of the triad of fever, cytopenia, and organomegaly. Treatment of adult HLH patients requires immunosuppression, with strict therapeutic guidance derived from the triggering disease. CONCLUSIONS Because of the similar clinical presentation to that of sepsis, HLH is often not recognized, resulting in a fatal outcome. In "sepsis" patients on the ICU with deterioration despite a standard of care, HLH needs to be considered by testing for ferritin when considering differential diagnoses. The complexity of the illness requires interdisciplinary patient care with specific integration of the hematologist in the diagnostic workup and therapeutic management, because of the frequent use of chemotherapy-based immunosuppression.
Collapse
|
50
|
Bonnecaze AK, Willeford WG, Lichstein P, Ohar J. Acute Cytomegalovirus (CMV) Infection Associated with Hemophagocytic Lymphohistiocytosis (HLH) in an Immunocompetent Host Meeting All Eight HLH 2004 Diagnostic Criteria. Cureus 2017; 9:e1070. [PMID: 28409071 PMCID: PMC5376153 DOI: 10.7759/cureus.1070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and often deadly syndrome characterized by severe inflammation and cytokine dysregulation. The disease is defined by the HLH-2004 criteria, requiring five of eight findings, and is further differentiated into either primary or secondary causes. Primary HLH tends to be of genetic etiology, while secondary HLH results from other insults such as infection. Secondary HLH is most commonly associated with viral infections in immunocompromised patients. Acute cytomegalovirus (CMV) associated HLH in the immunocompetent host is exceedingly rare and only documented in four case reports to date. We describe the fifth documented case of CMV-associated HLH in an immunocompetent patient, and furthermore, we demonstrate that this patient is the first published case of its type to satisfy all eight of HLH-2004 criteria.
Collapse
Affiliation(s)
- Alex K Bonnecaze
- Department of Internal Medicine, Wake Forest University Baptist Medical Center
| | - Wesley G Willeford
- Department of Internal Medicine, Wake Forest University Baptist Medical Center
| | - Peter Lichstein
- Department of Internal Medicine, Wake Forest University Baptist Medical Center
| | - Jill Ohar
- Department of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University Baptist Medical Center
| |
Collapse
|