1
|
Wang Y, Yuan X, Wang T, Wei W, Wu S, Hou H. Comprehensive evaluation of immune dysregulation in secondary hemophagocytic lymphohistiocytosis. Virulence 2024; 15:2342276. [PMID: 38629410 PMCID: PMC11028026 DOI: 10.1080/21505594.2024.2342276] [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: 11/20/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
Host immune dysfunction plays a crucial role in the onset, progression, and outcome of hemophagocytic lymphohistiocytosis (HLH). This study aimed to comprehensively evaluate the peripheral immune profiles in patients with newly diagnosed secondary hemophagocytic lymphohistiocytosis (sHLH), and explore their predictive value for patient prognosis. A total of 77 patients with sHLH were enrolled in this study, with 31 of them experiencing mortality. Flow cytometry was used to assess the percentages, absolute numbers, and phenotypes of lymphocyte subsets. Simultaneously, cytokine levels and routine laboratory indicators were also collected. In sHLH patients, lymphocyte subset absolute numbers were significantly impaired, accompanied by T cell hyperactivation, B cell hyperactivation, and increased plasmablast proliferation. Prognostic analysis revealed that lower CD8+ T cell percentages, elevated APTT, IL-6, IL-10 levels, and increased CD4+CD28null T cell proportions were associated with poor patient outcomes. The study demonstrates dysregulation in the counts and phenotypes of lymphocyte subsets in sHLH patients. Several key factors, including IL-6, IL-10, APTT, and various T cell percentages, have potential as prognostic markers and therapeutic targets in sHLH.
Collapse
Affiliation(s)
- Yun Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xu Yuan
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Wei
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiji Wu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongyan Hou
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
2
|
Kögl T, Chang HF, Staniek J, Chiang SC, Thoulass G, Lao J, Weißert K, Dettmer-Monaco V, Geiger K, Manna PT, Beziat V, Momenilandi M, Tu SM, Keppler SJ, Pattu V, Wolf P, Kupferschmid L, Tholen S, Covill LE, Ebert K, Straub T, Groß M, Gather R, Engel H, Salzer U, Schell C, Maier S, Lehmberg K, Cornu TI, Pircher H, Shahrooei M, Parvaneh N, Elling R, Rizzi M, Bryceson YT, Ehl S, Aichele P, Ammann S. Patients and mice with deficiency in the SNARE protein SYNTAXIN-11 have a secondary B cell defect. J Exp Med 2024; 221:e20221122. [PMID: 38722309 PMCID: PMC11082451 DOI: 10.1084/jem.20221122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 03/08/2024] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
SYNTAXIN-11 (STX11) is a SNARE protein that mediates the fusion of cytotoxic granules with the plasma membrane at the immunological synapses of CD8 T or NK cells. Autosomal recessive inheritance of deleterious STX11 variants impairs cytotoxic granule exocytosis, causing familial hemophagocytic lymphohistiocytosis type 4 (FHL-4). In several FHL-4 patients, we also observed hypogammaglobulinemia, elevated frequencies of naive B cells, and increased double-negative DN2:DN1 B cell ratios, indicating a hitherto unrecognized role of STX11 in humoral immunity. Detailed analysis of Stx11-deficient mice revealed impaired CD4 T cell help for B cells, associated with disrupted germinal center formation, reduced isotype class switching, and low antibody avidity. Mechanistically, Stx11-/- CD4 T cells exhibit impaired membrane fusion leading to reduced CD107a and CD40L surface mobilization and diminished IL-2 and IL-10 secretion. Our findings highlight a critical role of STX11 in SNARE-mediated membrane trafficking and vesicle exocytosis in CD4 T cells, important for successful CD4 T cell-B cell interactions. Deficiency in STX11 impairs CD4 T cell-dependent B cell differentiation and humoral responses.
Collapse
Affiliation(s)
- Tamara Kögl
- Institute for Immunology, Center for Microbiology and Hygiene, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| | - Hsin-Fang Chang
- Cellular Neurophysiology, Center for Integrative Physiology and Molecular Medicine, Saarland University, Homburg, Germany
| | - Julian Staniek
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Medical Center— University of Freiburg, Freiburg, Germany
| | - Samuel C.C. Chiang
- Division of Bone Marrow Transplantation and Immune Deficiency, and Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
- Department of Medicine, Center for Hematology and Regenerative Medicine Huddinge, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gudrun Thoulass
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Biology, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Jessica Lao
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Biology, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Kristoffer Weißert
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| | - Viviane Dettmer-Monaco
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Institute for Transfusion Medicine and Gene Therapy—University of Freiburg, Freiburg, Germany
| | - Kerstin Geiger
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Biology, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Institute for Transfusion Medicine and Gene Therapy—University of Freiburg, Freiburg, Germany
| | - Paul T. Manna
- Department of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Vivien Beziat
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Necker Hospital for Sick Children, Paris, France
- Imagine Institute, University of Paris-Cité, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
| | - Mana Momenilandi
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Necker Hospital for Sick Children, Paris, France
- Imagine Institute, University of Paris-Cité, Paris, France
| | - Szu-Min Tu
- Cellular Neurophysiology, Center for Integrative Physiology and Molecular Medicine, Saarland University, Homburg, Germany
| | - Selina J. Keppler
- Division of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Varsha Pattu
- Cellular Neurophysiology, Center for Integrative Physiology and Molecular Medicine, Saarland University, Homburg, Germany
| | - Philipp Wolf
- Department of Urology, Faculty of Medicine, Medical Center—University of Freiburg, Freiburg, Germany
| | - Laurence Kupferschmid
- Institute of Medical Microbiology and Hygiene, University Medical Center, Freiburg, Germany
| | - Stefan Tholen
- Department of Pathology, Institute of Surgical Pathology, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Laura E. Covill
- Department of Medicine, Center for Hematology and Regenerative Medicine Huddinge, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Karolina Ebert
- Institute for Immunology, Center for Microbiology and Hygiene, Medical Center—University of Freiburg, Freiburg, Germany
| | - Tobias Straub
- Institute for Immunology, Center for Microbiology and Hygiene, Medical Center—University of Freiburg, Freiburg, Germany
| | - Miriam Groß
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| | - Ruth Gather
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| | - Helena Engel
- Institute for Immunology, Center for Microbiology and Hygiene, Medical Center—University of Freiburg, Freiburg, Germany
| | - Ulrich Salzer
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Medical Center— University of Freiburg, Freiburg, Germany
| | - Christoph Schell
- Department of Pathology, Institute of Surgical Pathology, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Sarah Maier
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatjana I. Cornu
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Institute for Transfusion Medicine and Gene Therapy—University of Freiburg, Freiburg, Germany
| | - Hanspeter Pircher
- Institute for Immunology, Center for Microbiology and Hygiene, Medical Center—University of Freiburg, Freiburg, Germany
| | - Mohammad Shahrooei
- Department of Microbiology, Immunology, and Transplantation, Clinical and Diagnostic Immunology, KU Leuven, Leuven, Belgium
- Dr. Shahrooei Laboratory, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Parvaneh
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Roland Elling
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty for Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center—University of Freiburg, Freiburg, Germany
| | - Marta Rizzi
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Medical Center— University of Freiburg, Freiburg, Germany
- Division of Clinical and Experimental Immunology, Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
- Centre for Integrative Biological Signalling Studies, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Clinical Immunology, Medical Center—University of Freiburg, Freiburg, Germany
| | - Yenan T. Bryceson
- Department of Medicine, Center for Hematology and Regenerative Medicine Huddinge, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Broegelmann Laboratory, Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Stephan Ehl
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| | - Peter Aichele
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| | - Sandra Ammann
- Faculty of Medicine, Institute for Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Center for Chronic Immunodeficiency, Medical Center—University of Freiburg, Freiburg, Germany
| |
Collapse
|
3
|
Gioia C, Paroli M, Izzo R, Di Sanzo L, Rossi E, Pignatelli P, Accapezzato D. Pathogenesis of Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome: A Case Report and Review of the Literature. Int J Mol Sci 2024; 25:5921. [PMID: 38892108 PMCID: PMC11173133 DOI: 10.3390/ijms25115921] [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: 04/26/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by the uncontrolled activation of cytotoxic T lymphocytes, NK cells, and macrophages, resulting in an overproduction of pro-inflammatory cytokines. A primary and a secondary form are distinguished depending on whether or not it is associated with hematologic, infectious, or immune-mediated disease. Clinical manifestations include fever, splenomegaly, neurological changes, coagulopathy, hepatic dysfunction, cytopenia, hypertriglyceridemia, hyperferritinemia, and hemophagocytosis. In adults, therapy, although aggressive, is often unsuccessful. We report the case of a 41-year-old man with no apparent history of previous disease and an acute onset characterized by fever, fatigue, and weight loss. The man was from Burkina Faso and had made trips to his home country in the previous five months. On admission, leukopenia, thrombocytopenia, increased creatinine and transaminases, LDH, and CRP with a normal ESR were found. The patient also presented with hypertriglyceridemia and hyperferritinemia. An infectious or autoimmune etiology was ruled out. A total body CT scan showed bilateral pleural effusion and hilar mesenterial, abdominal, and paratracheal lymphadenopathy. Lymphoproliferative disease with HLH complication was therefore suspected. High doses of glucocorticoids were then administered. A cytologic analysis of the pleural effusion showed anaplastic lymphoma cells and bone marrow aspirate showed hemophagocytosis. An Epstein-Barr Virus (EBV) DNA load of more than 90000 copies/mL was found. Bone marrow biopsy showed a marrow localization of peripheral T lymphoma. The course was rapidly progressive until the patient died. HLH is a rare but usually fatal complication in adults of hematologic, autoimmune, and malignant diseases. Very early diagnosis and treatment are critical but not always sufficient to save patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (C.G.); (M.P.); (R.I.); (L.D.S.); (E.R.); (P.P.)
| |
Collapse
|
4
|
Gutierrez Sanchez LH, Ibrahim SH. Severe Acute Hepatitis of Unknown Etiology in Children: New Virus or Immune Dysregulation. Gastroenterology 2024:S0016-5085(24)00481-5. [PMID: 38663818 DOI: 10.1053/j.gastro.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 06/02/2024]
Affiliation(s)
- Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Samar H Ibrahim
- Division of Gastroenterology and Hepatology, Division of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
5
|
Lee BJ. Improved survival outcomes with anakinra over etoposide-based therapies for the management of adults with hemophagocytic lymphohistiocytosis: a retrospective multicenter research network study. Ther Adv Hematol 2024; 15:20406207241245517. [PMID: 38633898 PMCID: PMC11022673 DOI: 10.1177/20406207241245517] [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: 01/02/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening, hyperinflammatory syndrome for which etoposide-based regimens have historically been the standard of care. Recent reports have described positive outcomes with the utilization of ruxolitinib or anakinra although these studies are often limited to small samples. Objectives We aimed to compare the efficacy of ruxolitinib, anakinra, and etoposide-based therapies for the management of HLH in adult patients. Design We performed a population-based, multicenter, retrospective cohort study utilizing the TriNetX Networks database. Methods Adult patients (⩾18 years) diagnosed with HLH who received first-line treatment with ruxolitinib, anakinra, or etoposide between 2008 and 2023 were analyzed. The primary endpoint was overall survival (OS) at 1 year. A 1:1 propensity-score matching analysis was utilized. Results Anakinra (p = 0.020) but not ruxolitinib (p = 0.19) resulted in a significantly higher 1-year OS when compared with etoposide-based therapies. Conclusions Anakinra is effective for the management of adult patients with HLH.
Collapse
Affiliation(s)
- Benjamin J. Lee
- Department of Pharmacy, Chao Family Comprehensive Cancer Center, University of California Irvine Health, 101 The City Drive South, Building 23, Room 275, Orange, CA 92868, USA
- Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, Irvine, CA, USA
| |
Collapse
|
6
|
Su R, Zhang T, Wang H, Yan G, Wu R, Zhang X, Gao C, Li X, Wang C. New sights of low dose IL-2: Restoration of immune homeostasis for viral infection. Immunology 2024; 171:324-338. [PMID: 37985960 DOI: 10.1111/imm.13719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
Viral infection poses a significant threat to human health. In addition to the damage caused by viral replication, the immune response it triggers often leads to more serious adverse consequences. After the occurrence of viral infection, in addition to the adverse consequences of infection, chronic infections can also lead to virus-related autoimmune diseases and tumours. At the same time, the immune response triggered by viral infection is complex, and dysregulated immune response may lead to the occurrence of immune pathology and macrophage activation syndrome. In addition, it may cause secondary immune suppression, especially in patients with compromised immune system, which could lead to the occurrence of secondary infections by other pathogens. This can often result in more severe clinical outcomes. Therefore, regarding the treatment of viral infections, restoring the balance of the immune system is crucial in addition to specific antiviral medications. In recent years, scientists have made an interesting finding that low dose IL-2 (ld-IL-2) could potentially have a crucial function in regulating the immune system and reducing the chances of infection, especially viral infection. Ld-IL-2 exerts immune regulatory effects in different types of viral infections by modulating CD4+ T subsets, CD8+ T cells, natural killer cells, and so on. Our review summarised the role of IL-2 or IL-2 complexes in viral infections. Ld-IL-2 may be an effective strategy for enhancing host antiviral immunity and preventing infection from becoming chronic; additionally, the appropriate use of it can help prevent excessive inflammatory response after infection. In the long term, it may reduce the occurrence of infection-related autoimmune diseases and tumours by promoting the restoration of early immune homeostasis. Furthermore, we have also summarised the application of ld-IL-2 in the context of autoimmune diseases combined with viral infections; it may be a safe and effective strategy for restoring immune homeostasis without compromising the antiviral immune response. In conclusion, focusing on the role of ld-IL-2 in viral infections may provide a new perspective for regulating immune responses following viral infections and improving prognosis.
Collapse
Affiliation(s)
- Rui Su
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| | - Tingting Zhang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| | - Hui Wang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| | - Gaofei Yan
- Second department, Hamony Long Stomatological Hospital, Taiyuan, China
| | - Ruihe Wu
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| | - Xin Zhang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| | - Chong Gao
- Department of Pathology, Brigham and Women's Hospital/Children's Hospital Boston, Joint Program in Transfusion Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaofeng Li
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| | - Caihong Wang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Key Laboratory of Immunomicroecology, Taiyuan, Shanxi, China
| |
Collapse
|
7
|
Wang DD, Wu S, Kong BB, Song LL. Hemophagocytic lymphohistiocytosis with jaundice as first manifestation: A case report. World J Clin Cases 2023; 11:8212-8218. [PMID: 38130789 PMCID: PMC10731184 DOI: 10.12998/wjcc.v11.i34.8212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/11/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening condition. It is an immune-mediated disease that has a wide range of causes, elicits a hyperinflammatory response, and results in multiple organ damage. Clinical presentations vary, and in some cases, jaundice occurs as the first symptom. CASE SUMMARY We report the case of a 71-year-old female patient who presented with jaundice. She was admitted to our hospital because of the occurrence of "jaundice for half a month", and upon examination, obstructive jaundice with choledocholithiasis and gallstones was suggested. Cholecystectomy and choledocholithotomy were performed. However, the jaundice did not improve after surgery. We found splenomegaly, cytopenia, hypertriglyceridemia, hypofibrinogenemia, and elevated ferritin. Bone marrow biopsy revealed hemophagocytosis. Later, cardiac arrest occurred when she returned 3 wk after the surgery. We considered that HLH was triggered by septic shock. The patient's condition deteriorated rapidly, with multiple organ dysfunction and severe gastrointestinal bleeding. Corticosteroid therapy and symptomatic treatment failed to save her life. CONCLUSION Jaundice rarely presents as the first symptom in HLH patients. The HLH in this case was triggered by septic shock with jaundice as the first symptom. Clinicians should try hard to reduce missed diagnoses and misdiagnoses.
Collapse
Affiliation(s)
- Dan-Dan Wang
- Department of Emergency Medicine, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing 102218, China
| | - Sheng Wu
- Department of Emergency Medicine, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing 102218, China
| | - Bing-Bing Kong
- Department of Emergency Medicine, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing 102218, China
| | - Lin-Lin Song
- Department of Emergency Medicine, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing 102218, China
| |
Collapse
|
8
|
Hirade T, Abe Y, Ito S, Suzuki T, Katano H, Takahashi N, Koike D, Nariai A, Kato F. Congenital Echovirus 11 Infection in a Neonate. Pediatr Infect Dis J 2023; 42:1002-1006. [PMID: 37523578 DOI: 10.1097/inf.0000000000004052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Neonates infected with enterovirus in utero would be fulminant at birth or develop symptoms within a few days. Echovirus 11 causes life-threatening hepatic necrosis with coagulopathy and adrenal hemorrhagic necrosis. The prognosis depends on the enterovirus serotype and the absence of serotype-specific maternal antibodies at the time of delivery. We describe a fatal neonatal case of congenital echovirus 11 infection.
Collapse
Affiliation(s)
- Tomohiro Hirade
- From the Department of Pediatrics, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Yasuhiro Abe
- From the Department of Pediatrics, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Satoko Ito
- Department of Neonatology, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Tadaki Suzuki
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Harutaka Katano
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Naoto Takahashi
- Department of Pediatrics, University of Tokyo Hospital, Tokyo, Japan
| | - Daisuke Koike
- From the Department of Pediatrics, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Akiyoshi Nariai
- From the Department of Pediatrics, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Fumihide Kato
- Department of Neonatology, Shimane Prefectural Central Hospital, Shimane, Japan
| |
Collapse
|
9
|
Wang S, Lv K, Zhou Y, Cheng X, Chen Z, Shen H, Li F. A novel prognosis-prediction model based on coagulation indicators in secondary hemophagocytic lymphohistiocytosis. Ann Hematol 2023; 102:3251-3259. [PMID: 37561154 PMCID: PMC10567857 DOI: 10.1007/s00277-023-05398-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/01/2023] [Indexed: 08/11/2023]
Abstract
Secondary hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease. In the present retrospective study, we aimed to investigate coagulation disorders and their outcome implications in patients with secondary HLH. We evaluated clinical characteristics and the relationship between coagulation indices and prognosis in HLH patients (n = 141). The information, including clinical symptoms, laboratory indicators, and coagulation indices, was evaluated. Coagulation disorders and bleeding events occurred in 95 (67.4%) and 60 (42.6%) patients, respectively. A coagulation index analysis primarily showed elevated levels of D-Dimer, the international standardized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), and thrombin time (TT), while the prothrombin activity, fibrinogen levels, and platelet levels were significantly decreased. Dominant disseminated intravascular coagulation (DIC) occurred in 76 patients (53.9%). Patients with lymphoma-associated hemophagocytic syndrome (LAHS) frequently exhibited apparent coagulation disorders. Multivariate analysis revealed that age ≥ 29.5 years, bleeding events, APTT ≥ 47.3 s, fibrinogen ≤ 1.68 g/L, and absolute neutrophil counts (ANC) of ≤ 1.21 × 109/L were independent prognostic factors. We thereby devised a prognostic scoring system and stratified patients into low-risk (0-2 points), intermediate-risk (3-4 points), and high-risk (5-7 points) groups, and the 1-year overall survival rates in the above-mentioned groups were 66.40%, 40.00%, and 2.30%, respectively (P < 0.0001). In conclusion, coagulation dysfunctions and bleeding tendencies were common characteristics in HLH patients. We constructed a novel prognostic score model based on APTT, fibrinogen level, ANC, age, and bleeding events, which had superior prognostic value compared with these markers alone.
Collapse
Affiliation(s)
- Shixuan Wang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Kebing Lv
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yulan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Xiaoye Cheng
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhiwei Chen
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Huimin Shen
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China.
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, China.
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China.
| |
Collapse
|
10
|
Nagao M, Fukuda A, Tsujimura M, Nishioka Y, Umeda M, Matsumura T, Seno H. Hemophagocytic lymphohistiocytosis associated with hepatocellular carcinoma. Clin J Gastroenterol 2023; 16:698-701. [PMID: 37166565 DOI: 10.1007/s12328-023-01813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
A man in his 60s was admitted because of abdominal pain and fatigue. Contrast enhanced computed tomography (CECT) showed a hypovascular tumor, 7 cm in size, in the left lobe of liver. He had no history of alcohol consumption. HBs antigen and HCV antibody were negative. For definitive diagnosis, biopsy of the hepatic tumor was performed. After the biopsy, the patient suddenly got high fever, and blood tests showed WBC 22,000/L, Hb 8.9 g/dL, Plts 11.6 × 104/L, AST 140 IU/L, ALT 93 IU/L, LDH 635 U/L. He died on the following day despite of supportive therapy. Autopsy revealed that the hepatic tumor was poorly differentiated hepatocellular carcinoma (HCC) and that hemophagocytic macrophages were found in the bone marrow and spleen. Based on the pathological findings of autopsy, he was finally diagnosed with hemophagocytic lymphohistiocytosis (HLH) associated with HCC. HLH is a rare and life-threaded disorder of immune overactivation. Malignancy-associated HLH is well-known; however, it is usually associated with malignant lymphoma. To our knowledge, this is the first reported case of HLH associated with HCC, which was diagnosed by autopsy. Although extremely rare, our case highlights that HLH should be considered as a differential diagnosis of unknown high fever and bicytopenia in patients with solid tumors, including HCC.
Collapse
Affiliation(s)
- Munemasa Nagao
- Department of Gastroenterology and Hepatology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan.
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Akihisa Fukuda
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Marina Tsujimura
- Department of Diagnostic Pathology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashi Naniwa-cho, Amagasaki, Hyogo, 660-8550, Japan
| | - Yasuyuki Nishioka
- Department of Gastroenterology and Hepatology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashi Naniwa-cho, Amagasaki, Hyogo, 660-8550, Japan
| | - Makoto Umeda
- Department of Gastroenterology and Hepatology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashi Naniwa-cho, Amagasaki, Hyogo, 660-8550, Japan
| | - Takeshi Matsumura
- Department of Gastroenterology and Hepatology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashi Naniwa-cho, Amagasaki, Hyogo, 660-8550, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| |
Collapse
|
11
|
Lee BJ, Cao Y, Vittayawacharin P, É'Leima G, Rezk S, Reid J, Brem EA, Ciurea SO, Kongtim P. Anakinra versus etoposide-based therapy added to high-dose steroids for the treatment of secondary hemophagocytic lymphohistiocytosis. Eur J Haematol 2023. [PMID: 37385631 DOI: 10.1111/ejh.14030] [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: 05/11/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening, hyperinflammatory syndrome usually treated with high-dose steroids (HDS), often complemented with adjunct therapies, such as etoposide (HLH-94 protocol). Anakinra has been reported to effectively treat HLH; however, has not been comparatively examined with etoposide-based therapies. We sought to evaluate the effectiveness and durability of these treatment approaches. METHODS We performed a retrospective analysis of all adult patients diagnosed with secondary HLH between January 2011 and November 2022 who received anakinra and HDS, the HLH-94 protocol, HDS alone, or supportive care. RESULTS Thirty adult patients with secondary HLH were included. Cumulative incidence (CI) of response at 30 days was 83.3%, 60%, and 36.4% for patients treated with anakinra, the HLH-94 protocol, and HDS alone, respectively. CI of relapse at 1 year was 50%, 33.3%, and 0% with the HLH-94 protocol, HDS, and anakinra and HDS, respectively. Overall survival at 1 year was higher with anakinra and HDS compared to the HLH-94 protocol, yet was not statistically significant (77.8% vs. 33.3%; hazard ratio: 0.29; p = .25). CONCLUSION Treatment with anakinra and HDS in adults with secondary HLH was associated with higher response rates with longer survival compared with alternative therapies and should be further investigated in this setting.
Collapse
Affiliation(s)
- Benjamin J Lee
- Department of Pharmacy, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
- Department of Clinical Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University of California, Irvine, California, USA
| | - Yen Cao
- Division of Hematology Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Pongthep Vittayawacharin
- Division of Hematology Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ghaydá É'Leima
- Division of Hematology Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Sherif Rezk
- Department of Pathology and Laboratory Medicine, University of California Irvine Health, Orange, California, USA
| | - Jack Reid
- Department of Pathology and Laboratory Medicine, University of California Irvine Health, Orange, California, USA
| | - Elizabeth A Brem
- Division of Hematology Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Stefan O Ciurea
- Division of Hematology Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Piyanuch Kongtim
- Division of Hematology Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| |
Collapse
|
12
|
AlJabban A, Evans MG, Fell GG, Guccione JP, Edwards RA, Pinkus GS, Padera RF, Pozdnyakova O, Kim AS. Autopsy findings from patients diagnosed with COVID-19 demonstrate unique morphological patterns in bone marrow and lymph node. J Clin Pathol 2023:jcp-2023-208875. [PMID: 37290912 DOI: 10.1136/jcp-2023-208875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/30/2023] [Indexed: 06/10/2023]
Abstract
AIMS The identification of haemophagocytosis in bone marrow (BM) is recurrently identified in patients with severe COVID-19. These initial COVID-19 autopsy studies have afforded valuable insight into the pathophysiology of this disease; however, only a limited number of case series have focused on lymphoid or haematopoietic tissues. METHODS BM and lymph node (LN) specimens were obtained from adult autopsies performed between 1 April 2020 and 1 June 2020, for which the decedent had tested positive for SARS-CoV-2. Tissue sections (H&E, CD3, CD20, CD21, CD138, CD163, MUM1, kappa/lambda light chains in situ hybridisation) were examined by two haematopathologists, who recorded morphological features in a blinded fashion. Haemophagocytic lymphohistiocytosis (HLH) was assessed based on HLH 2004 criteria. RESULTS The BM demonstrated a haemophagocytic pattern in 9 out of 25 patients (36%). The HLH pattern was associated with longer hospitalisation, BM plasmacytosis, LN follicular hyperplasia and lower aspartate aminotransferase (AST), as well as ferritin at demise. LN examination showed increased plasmacytoid cells in 20 of 25 patients (80%). This pattern was associated with a low absolute monocyte count at diagnosis, lower white cell count and lower absolute neutrophil count at demise, and lower ferritin and AST at demise. CONCLUSIONS Autopsy results demonstrate distinct morphological patterns in BM, with or without haemophagocytic macrophages, and in LN, with or without increased plasmacytoid cells. Since only a minority of patients met diagnostic criteria for HLH, the observed BM haemophagocytic macrophages may be more indicative of an overall inflammatory state.
Collapse
Affiliation(s)
- Ali AlJabban
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Clinical Investigation, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark G Evans
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Geoffrey G Fell
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jack P Guccione
- Los Angeles County Department of Medical Examiner-Coroner, Los Angeles, California, USA
| | - Robert A Edwards
- Department of Pathology and Laboratory Medicine, University of California Irvine, Irvine, California, USA
| | - Geraldine S Pinkus
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert F Padera
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Annette S Kim
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Wi W, Yoon KW, Kim HJ. Secondary hemophagocytic lymphohistiocytosis associated with heat stroke: A case report and review of literature. Medicine (Baltimore) 2023; 102:e33842. [PMID: 37233425 PMCID: PMC10219742 DOI: 10.1097/md.0000000000033842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 05/27/2023] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a syndrome with potentially fatal consequences that results from an excessive immune response caused by malfunctioning natural killer cells and cytotoxic T lymphocytes. Secondary HLH, which is the predominant type in adults, is associated with various medical conditions, including infections, malignancies, and autoimmune diseases. Secondary HLH associated with heat stroke has not been reported. PATIENT CONCERNS A 74-year-old male was admitted to the emergency department after being unconscious in a 42°C hot public bath. The patient was witnessed to be in the water for more than 4 hours. The patient's condition was complicated by rhabdomyolysis and septic shock, which were managed with mechanical ventilation, vasoactive agents, and continuous renal replacement therapy. The patient also showed evidence of diffuse cerebral dysfunction. DIAGNOSES While the patient's condition initially improved, the patient developed a fever, anemia, thrombocytopenia, and an acute rise in total bilirubin, which, we suspected, was caused by HLH. Further investigations revealed elevated serum ferritin and soluble interleukin-2 receptor levels. INTERVENTIONS The patient received 2 cycles of serial therapeutic plasma exchange to lower the endotoxin burden. To manage HLH, high-dose glucocorticoid therapy was done. OUTCOMES Despite the best efforts, the patient did not recover and expired from progressive hepatic failure. LESSONS We report a novel case of secondary HLH associated with heat stroke. Diagnosing secondary HLH can be difficult since clinical manifestations of the underlying disease and HLH may present simultaneously. Early diagnosis and prompt initiation of treatment is required to improve the prognosis of the disease.
Collapse
Affiliation(s)
- Wongook Wi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Kyoung Won Yoon
- Division of Critical Care, Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Hyo Jin Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| |
Collapse
|
14
|
Irino K, Jinnouchi F, Nakano S, Sawabe T. A case of hemophagocytic lymphohistiocytosis with a significant response to baricitinib: a first report with review of literature. Clin Rheumatol 2023:10.1007/s10067-023-06579-8. [PMID: 36947281 DOI: 10.1007/s10067-023-06579-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/23/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a febrile disease with hyperinflammation characterized by activated macrophages with phagocytosis. The treatment strategy of secondary HLH has not been clearly established. Because of the high mortality rate and poor prognosis of HLH, alternative treatment strategies have been sought in treatment-resistant cases. Recently, there have been several reports that ruxolitinib, a Janus kinase (JAK) 1/JAK2 inhibitor, was effective against secondary HLH. Since the pathogenesis of HLH involves the overproduction of cytokines and JAK transmits a variety of cytokine signals, JAK inhibitors are thought to be effective in HLH. We herein report a case of HLH that was refractory to glucocorticoids, cyclosporine, and etoposide but responded to baricitinib. In the field of rheumatology, treatment-resistant cases of secondary HLH remain unmet needs. This is the first report to show that baricitinib was effective in a case of HLH. The accumulation of more cases in the future may prove that baricitinib is a potent agent for treating HLH.
Collapse
Affiliation(s)
- Kensuke Irino
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan.
| | - Fumiaki Jinnouchi
- Department of Hematology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Shota Nakano
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan
| | - Takuya Sawabe
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan
| |
Collapse
|
15
|
Benlamkaddem S, Doughmi D, Tlamçani I, Berdai MA, Harandou M. The Challenging Aspect of Macrophage Activation Syndrome in the Setting of Sepsis or Systemic Inflammatory Response Syndrome (SIRS). Cureus 2023; 15:e36228. [PMID: 37069877 PMCID: PMC10105518 DOI: 10.7759/cureus.36228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 03/18/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a rare but potentially fatal disease. It is characterized by hyperinflammation, including the proliferation and activation of immune cells (CD8 T cells and NK cells) associated with hypercytokinemia. Patients present with fever, splenomegaly, and cytopenia, associated with a hemophagocytosis picture in the bone marrow. It can progress to a multiorgan failure syndrome (MODS), mimicking sepsis or a systemic inflammatory response syndrome (SIRS). We report the case of an 8-year-old girl admitted to the pediatric intensive care unit for the management of major trauma due to a domestic accident. She presented with a protracted fever in the context of a septic shock, despite appropriate treatment. The association with bicytopenia, hyperferritinemia, hypofibrinogenemia, and hypertriglyceridemia was suggestive of MAS which was confirmed by a bone marrow puncture showing hemophagocytosis. A Bolus of corticotherapy was then added to the supportive treatment and broad-spectrum antibiotherapy, with a good outcome.
Collapse
|
16
|
Liu Q, Ye L, Li SG, Gao Y, Liu SS, Liu B, Li XX, Du WD. A simplified direct on-chip forward or reverse immunoassay for evaluating protein-protein interactions in the serum. Biotechnol J 2023; 18:e2200427. [PMID: 36420981 DOI: 10.1002/biot.202200427] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The identification of protein-protein interactions is a great challenge. In this study, we fabricated a gold surface-modified biochip with activated sophorolipids (SLs) in combination with 16-amino-1-hexadecanethiol hydrochloride to detect serum proteins. MAIN METHODS AND MAJOR RESULTS The on-chip immunoassay reported here included a forward assay, in which a ligand is immobilized on the biochip surface and allowed to interact with its free specific receptor in liquid phase, and a reverse assay, in which a receptor is loaded on the biochip surface and combined with its free specific ligand in solution. The specificity of the molecular interactions on the biochip was evaluated using immunological blocking assays and chemiluminescent immunoassays (CLIA). Hemophagocytic lymphohistiocytosis (HLH) serum was used to test the potential utilization of the biochip. Reverse receptor CD25-based interleukin (IL)-2 and forward ligand IL-2-based CD25 assays revealed that the limit of detection of the target proteins was as low as 156 and 78 pg/ml, respectively. Using receptor- or ligand-based platforms, we found that the positive rates of free IL-2 and soluble CD25 (sCD25) monomers in the sera of HLH patients were 14.3% and 71.4%, respectively. In addition, the biochip showed good compatibility with CLIA for the measurement of sCD25 (r = 0.77, p < 0.01). CONCLUSIONS AND IMPLICATIONS Biochip platforms, such as on-chip immunoprecipitation (IP), can be used to evaluate the interactions between proteins, ligands, and receptors, or enzymes and substrates in serum.
Collapse
Affiliation(s)
- Qian Liu
- Department of Pathology, School of Basic Medicine, Anhui Medical University, Hefei, P.R. China.,Department of Pathology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, P.R. China
| | - Lei Ye
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Song-Guo Li
- Department of Pathology, School of Basic Medicine, Anhui Medical University, Hefei, P.R. China
| | - Yi Gao
- Department of Pathology, School of Basic Medicine, Anhui Medical University, Hefei, P.R. China
| | - Sheng-Sheng Liu
- Department of Pathology, School of Basic Medicine, Anhui Medical University, Hefei, P.R. China
| | - Biao Liu
- Department of Pathology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, P.R. China
| | - Xiao-Xue Li
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Wei-Dong Du
- Department of Pathology, School of Basic Medicine, Anhui Medical University, Hefei, P.R. China
| |
Collapse
|
17
|
Joly JA, Vallée A, Bourdin B, Bourbonnais S, Patey N, Gaboury L, Théorêt Y, Decaluwe H. Combined IFN-γ and JAK inhibition to treat hemophagocytic lymphohistiocytosis in mice. J Allergy Clin Immunol 2023; 151:247-259.e7. [PMID: 35973477 DOI: 10.1016/j.jaci.2022.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory disease caused by genetic defects in the granule-mediated cytotoxic pathway. Success of hematopoietic cell transplantation, the only cure, is correlated with the extent of disease control before transplantation. Unfortunately, disease refractoriness and toxicities to standard chemotherapy-based regimens are fatal in a fraction of patients. Novel targeted immunotherapies, such as IFN-γ blocking antibodies or ruxolitinib, a Janus kinase (JAK) 1/2 inhibitor, are promising but only partially effective at controlling disease. OBJECTIVE We asked whether combinations of cytokine-targeted therapies, using antibodies or JAK inhibitor, work synergistically to counteract HLH. METHODS Genetically predisposed mice were infected and treated with distinct combinations of immunotherapies. Disease outcome was monitored and compared to monotherapies. RESULTS We showed that inhibiting IL-6 or IL-18 signaling in combination with IFN-γ blockade or ruxolitinib did not increase disease control compared to anti-IFN-γ antibodies or ruxolitinib monotherapies. In contrast, clinically relevant doses of ruxolitinib combined with low doses of anti-IFN-γ blocking antibodies corrected cytopenias, prevented overt neutrophilia, limited cytokinemia, and resolved HLH immunopathology and symptomatology. CONCLUSIONS Our findings demonstrate that IFN-γ blockade and ruxolitinib act synergistically to suppress HLH progression. This supports the use of combined cytokine-targeted therapies as a bridge to hematopoietic cell transplantation in severe familial hemophagocytic lymphohistiocytosis.
Collapse
Affiliation(s)
- Josée-Anne Joly
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Vallée
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada; Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montréal, Québec, Canada
| | - Benoîte Bourdin
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada
| | - Sara Bourbonnais
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada
| | - Natalie Patey
- Department of Pathology and Cellular Biology, Université de Montréal, Montréal, Québec, Canada
| | - Louis Gaboury
- Department of Pathology and Cellular Biology, Université de Montréal, Montréal, Québec, Canada; Histology and Molecular Pathology Research Unit, Institute for Research in Immunology and Cancer (IRIC), Université de Montréal, Montréal, Québec, Canada
| | - Yves Théorêt
- Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada
| | - Hélène Decaluwe
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada; Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montréal, Québec, Canada; Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada.
| |
Collapse
|
18
|
Hemophagocytic lymphohistiocytosis secondary to diffuse large B-cell lymphoma presenting with recurrent multi-territory infarcts: A case report. Radiol Case Rep 2023; 18:377-381. [DOI: 10.1016/j.radcr.2022.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/15/2022] [Accepted: 10/23/2022] [Indexed: 11/18/2022] Open
|
19
|
李 公, 金 月, 甘 雨, 陈 辰, 贾 园, 李 春. [Ruxolitinib as an effective treatment for panniculitis associated hemophagocytic syndrome: A report of 2 cases and literature review]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54:1208-1213. [PMID: 36533357 PMCID: PMC9761834 DOI: 10.19723/j.issn.1671-167x.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Indexed: 06/17/2023]
Abstract
Hemophagocytic syndrome (HPS) is a severe disease characterized by excessive release of inflammatory cytokines caused by abnormal activation of lymphocytes and macrophages, which can cause multiple organ damage and even death. Panniculitis is a disease characterized by inflammation of subcutaneous adipose tissue. We effectively treated 2 patients with panniculitis-associated HPS with ruxolitinib. Case 1: A 70-year-old male started with intermittent plantar swelling and pain, and then developed leukocytosis, mild anemia, multiple red maculopapules with painless subcutaneous nodules on the forehead, neck and bilateral lower legs. The patient was treated with prednisone and leflunomide for improvement. After that, repeated fever and rash occurred again. After admission to our hospital, we found his leukocyte and hemoglobin decreased, ferritin raised, fibrinogen and natural killer (NK) cell activity decreased, and hemophagocytic cells were found in bone marrow aspiration. The skin pathology was consistent with non-suppurative nodular panniculitis. He was diagnosed with nodular panniculitis associa-ted HPS. He was treated with glucocorticoid, cyclosporine, etoposide and gamma globule, but the disease was not completely controlled. After adjusting etoposide to ruxolitinib, his symptoms and abnormal laboratory findings returned to normal. After 2 months he stopped using ruxolitinib due to repeated infections. During the follow-up, though the prednisone dose was tapered, his condition was stable. Case 2: A 46-year-old female patient developed from intermittent fever, erythematous nodular rash with tenderness, leukopenia, and abnormal liver function. antibiotic therapy was ineffective. She improved after glucocorticoid treatment, and relapsed after glucocorticoid reduction. There were fever, limb nodules, erythema with ulcerative necrosis, intermittent abdominal pain when she came to our hospital. Blood examination showed that her white blood cells, red blood cells and platelets were decreased, fibrinogen was decreased, triglyceride was increased, ferritin and soluble interleukin-2 receptor(SIL-2R/sCD25) were significantly raised, and hemophagocytic cells were found in bone marrow aspiration. It was found that Epstein-Barr virus DNA was transiently positive, skin Staphylococcus aureus infection, and pulmonary Aspergillus flavus infection, but C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were normal, and no evidence of tumor and other infection was found. Skin pathology was considered panniculitis. The diagnosis was panniculitis, HPS and complicated infection. Antibiotic therapy and symptomatic blood transfusion were given first, but the disease was not controlled. Later, dexamethasone was given, and the condition improved, but the disease recurred after reducing the dose of dexamethasone. Due to the combination of multiple infections, the application of etoposide had a high risk of infection spread. Ruxolitinib, dexamethasone, and anti-infective therapy were given, and her condition remained stable after dexamethasone withdrawal. After 2 months of medication, she stopped using ruxolitinib. One week after stopping using ruxolitinib, she developed fever and died after 2 weeks of antibiotic therapy treatment in a local hospital. In conclusion, panniculitis and HPS are related in etiology, pathogenic mechanism and clinical manifestations. Abnormal activation of Janus-kinase and signal transduction activator of transcription pathway and abnormal release of inflammatory factors play an important role in the pathogenesis of the two diseases. The report suggests that ruxolitinib is effective and has broad prospects in the treatment of panniculitis associated HPS.
Collapse
Affiliation(s)
- 公明 李
- 临沂市中医医院风湿病科,山东临沂 276003Department of Rheumatology, Linyi Traditional Chinese Medicine Hospital, Linyi 276003, Shandong, China
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 月波 金
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 雨舟 甘
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 辰 陈
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 园 贾
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 春 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| |
Collapse
|
20
|
Hegazy S, Moesch J, Guerrero A, Ho J, Karunamurthy A. Random Skin Biopsy Is a Useful Procedure in the Evaluation of Hemophagocytic Lymphohistiocytosis: A Case Report and Review of Literature. Am J Dermatopathol 2022; 44:925-928. [PMID: 36197063 DOI: 10.1097/dad.0000000000002301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACT Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening syndrome, characterized by aberrant activation of T lymphocytes and macrophages leading to hypercytokinemia. HLH can be familial or a result of various secondary etiologies. We present a case of a 46-year-old woman with a past medical history of multiple sclerosis on rituximab who presented as a transfer from an outside hospital with numerous clinical abnormalities including recurrent episodes of fever of unknown origin for 3 weeks, persistent leukocytosis, hypertriglyceridemia, and steatohepatitis. Given the uncertain nature of her illness, she underwent a random skin biopsy from the abdominal region to exclude hematolymphoid malignancy. Histopathology revealed a brisk histiocytic rich dermal infiltrate accompanied by perivascular lymphocytic infiltrate. The histiocytes were enlarged and positive for muraminadase and CD68 stains exhibiting hemophagocytosis focally. As per the HLH-2004 protocol, our patient met the diagnostic criteria of HLH. Concurrent bone marrow biopsy revealed similar rare hemophagocytosis. Cytogenetics and molecular studies were negative, supporting secondary HLH.
Collapse
Affiliation(s)
- Shaymaa Hegazy
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | | | |
Collapse
|
21
|
Summerlin J, Wells DA, Anderson MK, Halford Z. A Review of Current and Emerging Therapeutic Options for Hemophagocytic Lymphohistiocytosis. Ann Pharmacother 2022:10600280221134719. [DOI: 10.1177/10600280221134719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective: To provide an overview of clinical sequelae and emerging treatment options for hemophagocytic lymphohistiocytosis (HLH). Data Sources: A literature search was conducted using the search terms “hemophagocytic lymphohistiocytosis,” “hemophagocytic syndrome,” “macrophage activation syndrome,” and “treatment” on Ovid and PubMed from January 1, 2017, through September 28, 2022. Study Selection and Data Extraction: Relevant clinical trials, meta-analyses, case reports, review articles, package inserts, and guidelines to identify current and emerging therapeutic options for the management of HLH. Data Synthesis: Genetic disorders and secondary causes may trigger HLH in both children and adults. Notable improvements in the diagnosis of HLH were seen with implementation of the HLH-2004 standard diagnostic criteria; however, timely and accurate identification of HLH remain significant barriers to optimal management. Multiagent immunochemotherapy are the backbone of aggressive therapy for acutely ill patients with HLH. Relevance to Patient Care and Clinical Practice: The global coronavirus 2019 (COVID-19) pandemic and emerging immune effector cell therapies have served to highlight the concerns with immune dysregulation and subsequent HLH precipitation. Without prompt identification and treatment, HLH can be fatal. Historically, the clinician’s armamentarium for managing HLH was sparse, with etoposide-based protocols serving as the standard of care. Relapsed or refractory disease portends a poor prognosis and requires additional treatment options. Second- or subsequent-line options now include hematopoietic stem cell transplantation, emapalumab, alemtuzumab, anakinra, ruxolitinib, and tocilizumab. Conclusions: Improvements in diagnostic methods and novel immunosuppressive treatment strategies, including noncytotoxic immunochemotherapy, have transformed the therapeutic landscape. Unfortunately, many unanswered questions remain. Additional studies are required to optimize dosing, schedules, treatment sequences, and indications for novel treatment options.
Collapse
Affiliation(s)
- Jenna Summerlin
- Division of Pharmacy Practice, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Drew A. Wells
- Internal Medicine, Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | | | | |
Collapse
|
22
|
Hadžić N, Molnar E, Height S, Kovács G, Dhawan A, Andrikovics H, Worth A, Gilmour KC. High Prevalence of Hemophagocytic Lymphohistiocytosis in Acute Liver Failure of Infancy. J Pediatr 2022; 250:67-74.e1. [PMID: 35835228 DOI: 10.1016/j.jpeds.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To investigate the prevalence of hemophagocytic lymphohistiocytosis (HLH) syndrome in pediatric acute liver failure (PALF) of infancy and assess the diagnostic role of rapid immunologic tests, genotype/phenotype correlations, and clinical outcomes. STUDY DESIGN We retrospectively analyzed 78 children with PALF aged <24 months referred over almost 2 decades. The studied patients with a phenotype of HLH syndrome had a comprehensive immunologic workup, including additional genetic analysis for primary immunologic causes. RESULTS Thirty of the 78 children had the HLH phenotype and underwent genetic assessment, which demonstrated positive findings in 19 (63.3%), including 9 (30%) with biallelic primary HLH mutations and 10 (33.3%) with heterozygous mutations and/or polymorphisms. The most common form of primary HLH was familial hemophagocytic lymphohistiocytosis (FHL)-2, diagnosed in 6 children, 4 of whom had a c.50delT (p.Leu17ArgfsTer34) mutation in the PRF1 gene. Three patients with primary HLH received genetic diagnoses of FHL-3, Griscelli syndrome, and LRBA (lipopolysaccharide-responsive vesicle trafficking, beach- and anchor-containing) protein deficiency. Overall mortality in the series was 52.6% (10 of 19), and mortality in children with a documented biallelic pathogenic HLH mutation (ie, primary HLH) was 66.6% (6 of 9). Two children underwent liver transplantation, and 4 children underwent emergency hematopoietic stem cell transplantation; all but 1 child survived medium term. CONCLUSIONS Primary HLH can be diagnosed retrospectively in approximately one-third of infants with indeterminate PALF (iPALF) who meet the clinical criteria for HLH, often leading to their death. The most common HLH type in iPALF is FHL-2, caused by biallelic mutations in PRF-1. The clinical relevance of observed heterozygous mutations and variants of uncertain significance requires further investigation. Prompt hematopoietic stem cell transplantation could be life-saving in infants who survive the liver injury.
Collapse
Affiliation(s)
- Nedim Hadžić
- Paediatric Liver Service, King's College Hospital, London, United Kingdom.
| | - Emese Molnar
- Department of Immunology, Camelia Bothnar Laboratories, Great Ormond Street Hospital, London, United Kingdom; Department of Rheumatology and Clinical Immunology, Semmelweis University, Budapest, Hungary
| | - Sue Height
- Department of Haematology, King's College Hospital, London, United Kingdom
| | - Gabor Kovács
- Department of Physiology, Semmelweis University, Budapest, Hungary
| | - Anil Dhawan
- Paediatric Liver Service, King's College Hospital, London, United Kingdom
| | - Hajnalka Andrikovics
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest, Budapest, Hungary
| | - Austen Worth
- Department of Immunology, Camelia Bothnar Laboratories, Great Ormond Street Hospital, London, United Kingdom
| | - Kimberly C Gilmour
- Department of Immunology, Camelia Bothnar Laboratories, Great Ormond Street Hospital, London, United Kingdom
| |
Collapse
|
23
|
Paolino J, Berliner N, Degar B. Hemophagocytic lymphohistiocytosis as an etiology of bone marrow failure. Front Oncol 2022; 12:1016318. [PMID: 36387094 PMCID: PMC9647152 DOI: 10.3389/fonc.2022.1016318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of multiorgan system dysfunction that is caused by hypercytokinemia and persistent activation of cytotoxic T lymphocytes and macrophages. A nearly ubiquitous finding and a diagnostic criterion of HLH is the presence of cytopenias in ≥ 2 cell lines. The mechanism of cytopenias in HLH is multifactorial but appears to be predominantly driven by suppression of hematopoiesis by pro-inflammatory cytokines and, to some extent, by consumptive hemophagocytosis. Recognition of cytopenias as a manifestation of HLH is an important consideration for patients with bone marrow failure of unclear etiology.
Collapse
Affiliation(s)
- Jonathan Paolino
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Nancy Berliner
- Division of Hematology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Barbara Degar
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States,*Correspondence: Barbara Degar,
| |
Collapse
|
24
|
Kim JY, Kim M, Park JK, Lee EB, Park JW, Hong J. Limited efficacy of tocilizumab in adult patients with secondary hemophagocytic lymphohistiocytosis: a retrospective cohort study. Orphanet J Rare Dis 2022; 17:363. [PMID: 36131317 PMCID: PMC9490693 DOI: 10.1186/s13023-022-02516-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Interleukin (IL)-6 is one of the key cytokines in the pathogenesis of secondary hemophagocytic lymphohistiocytosis (sHLH); however, the efficacy and safety of tocilizumab (TCZ), a monoclonal IL-6 receptor antibody, in patients with sHLH is uncertain.
Methods/Results This study included 64 adult patients who were diagnosed with sHLH based on the HLH-2004 criteria. Patients were classified into two groups based on treatment regimen at baseline: tocilizumab (TCZ group, n = 8) versus other treatments (control group), including HLH-2004 protocol (n = 35), chemotherapy (n = 7), glucocorticoid alone (n = 8), and with other immunosuppressants (n = 6). Primary outcome was overall 8-week survival. Baseline characteristics between the two groups were comparable. At day 56, one patient (12.5%) in the TCZ group and twenty-eight patients (51.9%) in the control group survived. Univariable and multivariable Cox proportional hazard analysis showed that TCZ significantly increased the risk of death (adjusted hazard ratio 5.55; 95% CI 2.13–14.49). The complete or partial response rate at day 14 was 44.6% in the control group, and nil in the TCZ group. In contrast, infectious complications occurred more frequently in the TCZ group than in the control group (14.3% vs. 50.0%). Conclusion Our results suggest that tocilizumab has limited efficacy in treating adult patients with sHLH and could increase the risk of infectious complications compared to the conventional treatments. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02516-1.
Collapse
Affiliation(s)
- Ju Yeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Miso Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Junshik Hong
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| |
Collapse
|
25
|
Bi X, Zhang Q, Chen L, Liu D, Li Y, Zhao X, Zhang Y, Zhang L, Liu J, Wu C, Li Z, Zhao Y, Ma H, Huang G, Liu X, Wang QF, Zhang R. NBAS, a gene involved in cytotoxic degranulation, is recurrently mutated in pediatric hemophagocytic lymphohistiocytosis. J Hematol Oncol 2022; 15:101. [PMID: 35902954 PMCID: PMC9331571 DOI: 10.1186/s13045-022-01318-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), particularly primary HLH (pHLH), is a rare, life-threatening disease. Germline genetic deficiency of 12 known HLH genes impairs cytotoxic degranulation in natural killer (NK) cells or cytotoxic T lymphocytes (CTLs) and contributes to pHLH development. However, no pathogenic mutations in these HLH genes are found in nearly 10% of HLH patients, despite a strong suspicion of pHLH, suggesting that the underlying genetic basis of HLH is still unclear. To discover novel susceptibility genes, we first selected 13 children with ppHLH (presumed primary HLH patients in the absence of detectable known HLH gene variants) and their parents for initial screening. Whole-genome sequencing (WGS) in one trio and whole-exome sequencing (WES) in twelve trios revealed that two ppHLH patients carried biallelic NBAS variants, a gene that is involved in Golgi-to-endoplasmic reticulum (ER) retrograde transport upstream of the degranulation pathway. Additionally, two candidate genes, RAB9B and KLC3, showed a direct relationship with known HLH genes in protein-protein interaction (PPI) network analysis. We analyzed NBAS, RAB9B, KLC3 and known HLH genes in an independent validation cohort of 224 pediatric HLH patients. Only biallelic NBAS variants were identified in three patients who harbored no pathogenic variants in any of the known HLH genes. Functionally, impaired NK-cell cytotoxicity and degranulation were revealed in both NBAS biallelic variant patients and in an NBAS-deficient NK-cell line. Knockdown of NBAS in an NK-cell line (IMC-1) using short hairpin RNA (shRNA) resulted in loss of lytic granule polarization and a decreased number of cytotoxic vesicles near the Golgi apparatus. According to our findings, NBAS is the second most frequently mutated gene (2.11%) in our HLH cohort after PRF1. NBAS deficiency may contribute to the development of HLH via a dysregulated lytic vesicle transport pathway.
Collapse
Affiliation(s)
- Xiaoman Bi
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China.,Key Laboratory of Tropical Translational Medicine of Ministry of Education, College of Biomedical Information and Engineering, Hainan Medical University, Haikou, 571199, China
| | - Qing Zhang
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Lei Chen
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Dan Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China
| | - Yueying Li
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China
| | - Xiaoxi Zhao
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Ya Zhang
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Liping Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jingkun Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Chaoyi Wu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Zhigang Li
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Yunze Zhao
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Honghao Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Gang Huang
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Xin Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China. .,China National Center for Bioinformation, Beijing, 100045, China. .,University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China. .,China National Center for Bioinformation, Beijing, 100045, China. .,University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Rui Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
| |
Collapse
|
26
|
Budhathoki P, Qureshi ZA, Shah A, Khanal S, Ghazanfar H, Hanif A. A Case of Severe Epstein–Barr Virus-Associated Hemophagocytic Lymphohistiocytosis Successfully Treated With High Dose Steroids and Ganciclovir. Cureus 2022; 14:e25952. [PMID: 35855250 PMCID: PMC9284470 DOI: 10.7759/cureus.25952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/05/2022] Open
|
27
|
Abou Shaar R, Perry KD, Otrock ZK. Hemophagocytosis on ascitic fluid cytology: Diagnosis of HLH. Diagn Cytopathol 2022; 50:414-416. [PMID: 35674130 DOI: 10.1002/dc.24999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/11/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of pathologic immune response characterized by excessive activation of macrophages. Hemophagocytosis is one of the diagnostic criteria for HLH, and it usually involves the bone marrow, spleen, lymph nodes, or any part of the reticuloendothelial system. Hemophagocytosis in the ascitic fluid has rarely been reported in HLH. Here, we report the case of a patient who presented with fever and abdominal distention and ascites. Ascitic fluid cytology showed hemophagocytosis which was the clue for HLH diagnosis. We also review the literature for this rare cytological occurrence.
Collapse
Affiliation(s)
- Rand Abou Shaar
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kyle D Perry
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| |
Collapse
|
28
|
Wang R, Li T, Ye S, Lv L, Chen S, Wang X, Bao CD, Fu Q. Short-term, low-dose etoposide in refractory adult-onset Still's disease-associated macrophage activation syndrome. Clin Rheumatol 2022; 41:2817-2823. [PMID: 35590113 DOI: 10.1007/s10067-022-06184-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In this study, we modified the classical regimen of the hemophagocytic lymphohistiocytosis-04 protocol and evaluated the efficacy and safety of short-term, low-dose etoposide in patients with refractory macrophage activation syndrome (MAS) associated with adult-onset Still's disease (AOSD). METHODS A total of 17 patients with refractory AOSD-associated MAS were enrolled and received short-term, low-dose etoposide (100 mg twice a week for four times). Another 11 patients, who were not treated with etoposide, were included as historical controls. Patient information, such as clinical manifestations, laboratory results, treatments, and short-term prognosis, were recorded and analyzed. RESULTS In this case series, 88.24% of the patients with MAS who were treated with short-term, low-dose etoposide had a favorable response in 3 weeks, which was significantly higher (p = 0.017) than that in the patients with MAS who were treated without etoposide (45.45%). The 90-day survival rate after the onset of MAS was significantly higher (p = 0.0029) among the patients in the short-term etoposide group (16/17, 94.12%) than in the control group (5/11, 45.45%). CONCLUSION The regimen of short-term (2 weeks), low-dose etoposide was highly effective in the treatment for patients with refractory AOSD-associated MAS with an acceptable safety profile. Key Points • There is no high level evidence to guide the management of refractory MAS-associated AOSD patients. • This study was the first to propose and confirm the efficacy and safety of short-term, low-dose etoposide in the treatment of refractory MAS-associated AOSD patients.
Collapse
Affiliation(s)
- Ran Wang
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Ting Li
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Shuang Ye
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Liangjin Lv
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Sheng Chen
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Xiaodong Wang
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Chun-de Bao
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China.
| | - Qiong Fu
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China.
| |
Collapse
|
29
|
Kumar D, Rostad CA, Jaggi P, Villacis Nunez DS, Prince C, Lu A, Hussaini L, Nguyen TH, Malik S, Ponder LA, Shenoy SPV, Anderson EJ, Briones M, Sanz I, Prahalad S, Chandrakasan S. Distinguishing immune activation and inflammatory signatures of multisystem inflammatory syndrome in children (MIS-C) versus hemophagocytic lymphohistiocytosis (HLH). J Allergy Clin Immunol 2022; 149:1592-1606.e16. [PMID: 35304157 PMCID: PMC8923010 DOI: 10.1016/j.jaci.2022.02.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening sequela of severe acute respiratory syndrome coronavirus 2 infection characterized by hyperinflammation and multiorgan dysfunction. Although hyperinflammation is a prominent manifestation of MIS-C, there is limited understanding of how the inflammatory state of MIS-C differs from that of well-characterized hyperinflammatory syndromes such as hemophagocytic lymphohistiocytosis (HLH). OBJECTIVES We sought to compare the qualitative and quantitative inflammatory profile differences between patients with MIS-C, coronavirus disease 2019, and HLH. METHODS Clinical data abstraction from patient charts, T-cell immunophenotyping, and multiplex cytokine and chemokine profiling were performed for patients with MIS-C, patients with coronavirus disease 2019, and patients with HLH. RESULTS We found that both patients with MIS-C and patients with HLH showed robust T-cell activation, markers of senescence, and exhaustion along with elevated TH1 and proinflammatory cytokines such as IFN-γ, C-X-C motif chemokine ligand 9, and C-X-C motif chemokine ligand 10. In comparison, the amplitude of T-cell activation and the levels of cytokines/chemokines were higher in patients with HLH when compared with patients with MIS-C. Distinguishing inflammatory features of MIS-C included elevation in TH2 inflammatory cytokines such as IL-4 and IL-13 and cytokine mediators of angiogenesis, vascular injury, and tissue repair such as vascular endothelial growth factor A and platelet-derived growth factor. Immune activation and hypercytokinemia in MIS-C resolved at follow-up. In addition, when these immune parameters were correlated with clinical parameters, CD8+ T-cell activation correlated with cardiac dysfunction parameters such as B-type natriuretic peptide and troponin and inversely correlated with platelet count. CONCLUSIONS Overall, this study characterizes unique and overlapping immunologic features that help to define the hyperinflammation associated with MIS-C versus HLH.
Collapse
Affiliation(s)
- Deepak Kumar
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Christina A Rostad
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Preeti Jaggi
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - D Sofia Villacis Nunez
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Chengyu Prince
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Austin Lu
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Laila Hussaini
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Thinh H Nguyen
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Sakshi Malik
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, Ga; Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Ga
| | | | - Sreekala P V Shenoy
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Evan J Anderson
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Department of Medicine, Emory University School of Medicine, Atlanta, Ga
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Ignacio Sanz
- Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, Ga; Lowance Center for Human Immunology, Emory University, Atlanta, Ga
| | - Sampath Prahalad
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Department of Human Genetics, Emory University School of Medicine, Atlanta, Ga
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga.
| |
Collapse
|
30
|
Cooray S, Sabanathan S, Hacohen Y, Worth A, Eleftheriou D, Hemingway C. Treatment Strategies for Central Nervous System Effects in Primary and Secondary Haemophagocytic Lymphohistiocytosis in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose of Review
This review presents an appraisal of current therapeutic options for the treatment of central nervous system haemophagocytic lymphohistiocytosis (CNS-HLH) in the context of systemic disease, as well as when CNS features occur in isolation. We present the reader with a diagnostic approach to CNS-HLH and commonly used treatment protocols. We discuss and evaluate newer treatments on the horizon.
Recent Findings
Mortality is high in patients who do not undergo HSCT, and while larger studies are required to establish benefit in many treatments, a number of new treatments are currently being evaluated. Alemtuzumab is being used as a first-line treatment for CNS-HLH in a phase I/II multicentre prospective clinical trial as an alternative to traditional HLH-1994 and 2004 protocols. It has also been used successfully as a second-line agent for the treatment of isolated CNS-HLH that is refractory to standard treatment. Ruxolitinib and emapalumab are new immunotherapies that block the Janus kinase—Signal Transducer and Activator of Transcription (JAK-STAT) pathway that have shown efficacy in refractory HLH, including for CNS-HLH disease.
Summary
Treatment of CNS-HLH often requires HLH-94 or 2004 protocols followed by haematopoietic stem cell transplantation (HSCT) to maintain remission, although relapse can occur, particularly with reduced intensity conditioning if donor chimerism falls. CNS features have been shown to improve or stabilise following HSCT in CNS-HLH in the context of systemic disease and in isolated CNS-HLH. Encouraging reports of early cohort studies suggest alemtuzumab and the Janus kinase (JAK) inhibitor ruxolitinib offer potential salvage therapy for relapsed and refractory CNS-HLH. Newer immunotherapies such as tocilizumab and natalizumab have been shown to be beneficial in sporadic cases. CNS-HLH due to primary gene defects may be amenable to gene therapy in the future.
Collapse
|
31
|
Wan Mohd Zohdi WA, Ismail AZ, Yusof N, Ithnin A, Shuib S, Masir N, Palaniappan S, Tumian NR. Rare but Potentially Fatal Presentations of Diffuse Large B-cell Lymphoma: Leukemic Phase or Hemophagocytic Syndrome in Bone Marrow. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2022; 15:2632010X211070774. [PMID: 35036912 PMCID: PMC8753065 DOI: 10.1177/2632010x211070774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a type of non-Hodgkin Lymphoma commonly presenting as a solid tumor either by nodal or extra-nodal manifestations. Here we describe two atypical presentations of lymphoma, finally resulting in the diagnosis of DLBCL. Case 1: A 53-year-old man with a previous history of nasopharyngeal carcinoma presented with a two-week history of B-symptoms and hyperleukocytosis. Peripheral blood film showed 78% abnormal mononuclear cells. Immunohistochemical stain showing Ki-67 of 90%, negative c-myc, BCL2 and BCL6, and negative c-MYC with fluorescence in-situ hybridization studies on the trephine biopsy, concluded the diagnosis of CD5+ DLBCL of ABC subtype. He received intravenous cyclophosphamide and oral prednisolone for cytoreduction, followed by 6 cycles of chemo-immunotherapy. However, he succumbed due to severe sepsis after the completion of therapy. Case 2: A 56-year-old lady who was initially investigated for pyrexia of unknown origin was noted to have hemophagocytosis upon bone marrow aspirate examination. The bone marrow trephine biopsy revealed some atypical clusters of B-cells positive for CD20 which was inconclusive. PET-CT scan noted an enlarged hypermetabolic spleen without lymphadenopathy. Splenic biopsy with immunohistochemical studies revealed DLBCL of ABC subtype. The diagnosis was consistent with primary splenic DLBCL. She became unwell post splenic biopsy and was admitted to the intensive care unit where she passed away 2 weeks later from Candida and Sternotrophomonas septicemia. These cases highlight the atypical presentations of a common subtype of NHL in our center. Arriving at the definitive diagnosis can be difficult especially when patients are acutely ill, hampering the necessary invasive procedures for diagnosis. The outcomes of both cases are briefly discussed hoping to spread awareness among clinicians on the rare and acutely critical presentations of DLBCL.
Collapse
Affiliation(s)
| | - Ahmad Zulhimi Ismail
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Nurasyikin Yusof
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Azlin Ithnin
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Salwati Shuib
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Noraidah Masir
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Sivakumar Palaniappan
- Department of Medicine, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Nor Rafeah Tumian
- Department of Medicine, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| |
Collapse
|
32
|
Li Y, Sun C, Cui L, Wang Q. NLRC4 Gene Single Nucleotide Polymorphisms Are Associated with the Prognosis of Hemophagocytic Lymphohistiocytosis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:8581746. [PMID: 34925545 PMCID: PMC8683185 DOI: 10.1155/2021/8581746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze and study the correlation between NLR family CARD domain-containing 4 (NLRC4) gene single nucleotide polymorphisms and the prognosis of patients with hemophagocytic lymphohistiocytosis (HLH). METHODS In this study, we retrospectively studied the clinical data of 62 HLH patients, including 40 males and 22 females. The genomic DNA was extracted, and the genotypes at rs385076 locus and rs479333 locus of the NLRC4 gene were analyzed. The level of blood interleukin-18 (IL-18) was analyzed by enzyme-linked immunosorbent assay (ELISA). RESULTS Compared with the TT genotype at the NLRC4 gene rs385076 locus, the mortality of HLH patients with TC genotype and CC genotype was higher (RR = 3.205, 95% CI: 1.277-4.788, p = 0.012; RR = 3.052, 95% CI: 1.098-4.753, p = 0.031). Taking the CC genotype at rs479333 of the NLRC4 gene as a reference, HLH patients with CG genotype and GG genotype had a higher risk of death (RR = 3.475, 95% CI: 1.488-5.775, p = 0.003; RR = 2.986, 95% CI: 1.014-5.570, p = 0.047). NLRC4 gene rs385076 T>C and rs479333 C>G were significantly related to the poor prognosis of HLH patients. The area under the curve (AUC) of the receiver operating curve (ROC) for the prognostic outcome of HLH with serum IL-18 level was 0.6813 (95% CI: 0.5365-0.8260, p = 0.0189). NLRC4 gene rs385076 T>C and rs479333 C>G were related to higher serum IL-18 levels. CONCLUSION NLRC4 gene rs385076 T>C and rs479333 C>G are related to the poor prognosis of HLH patients.
Collapse
Affiliation(s)
- Yan Li
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Chengdong Sun
- Department of Infectious Diseases, Beijing Jishuitan Hospital, Beijing 100096, China
| | - Liying Cui
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Qiuying Wang
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| |
Collapse
|
33
|
Geem D, Jiang W, Rytting HB, Chandrakasan S, Salem A, Stevens JP, Karpen SJ, Magliocca JF, Romero R, Rodriguez DS. Resolution of recurrent pediatric acute liver failure with liver transplantation in a patient with NBAS mutation. Pediatr Transplant 2021; 25:e14084. [PMID: 34288298 PMCID: PMC8515489 DOI: 10.1111/petr.14084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/17/2021] [Accepted: 06/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric acute liver failure (PALF) remains an enigmatic process of rapid end-organ dysfunction associated with a variety of pathologic conditions though the predominant cause is indeterminate. A growing body of research has identified mutations in the NBAS gene to be associated with recurrent acute liver failure and multi-systemic disease including short stature, skeletal dysplasia, facial dysmorphism, immunologic abnormalities, and Pelger-Huët anomaly. METHODS AND RESULTS Here, we describe a 4-year-old girl who presented with dehydration in the setting of acute gastroenteritis and fever but went on to develop PALF on day 2 of hospitalization. She clinically recovered with supportive measures, but after discharge, had at least 2 additional episodes of PALF. Ultimately, she underwent liver transplant and her recurrent episodes of PALF did not recur throughout a 6-year follow-up period. Whole-exome sequencing post-liver transplant initially revealed two variants of uncertain significance in the NBAS gene. Parental studies confirmed the c.1549C > T(p.R517C; now likely pathogenic) variant from her mother and a novel c.4646T > C(p.L1549P) variant from her father. In silico analyses predicted these variants to have a deleterious effect on protein function. Consistent with previously characterized NBAS mutation-associated disease (NMAD), our patient demonstrated the following features: progeroid facial features, hypoplasia of the 12th ribs, Pelger-Huët anomaly on peripheral blood smear, and abnormal B and NK cell function. CONCLUSION Altogether, we describe a novel pathogenic variant in the NBAS gene of a patient with NMAD and report the resolution of recurrent PALF secondary to NMAD following liver transplantation.
Collapse
Affiliation(s)
- Duke Geem
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Heather B. Rytting
- Department of Pathology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Salem
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - James P. Stevens
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Saul J. Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph F. Magliocca
- Department of Surgery, Transplant, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Dellys Soler Rodriguez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
34
|
Lenz D, Pahl J, Hauck F, Alameer S, Balasubramanian M, Baric I, Boy N, Church JA, Crushell E, Dick A, Distelmaier F, Gujar J, Indolfi G, Lurz E, Peters B, Schwerd T, Serranti D, Kölker S, Klein C, Hoffmann GF, Prokisch H, Greil J, Cerwenka A, Giese T, Staufner C. NBAS Variants Are Associated with Quantitative and Qualitative NK and B Cell Deficiency. J Clin Immunol 2021; 41:1781-1793. [PMID: 34386911 PMCID: PMC8604887 DOI: 10.1007/s10875-021-01110-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/23/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Biallelic pathogenic NBAS variants manifest as a multisystem disorder with heterogeneous clinical phenotypes such as recurrent acute liver failure, growth retardation, and susceptibility to infections. This study explores how NBAS-associated disease affects cells of the innate and adaptive immune system. METHODS Clinical and laboratory parameters were combined with functional multi-parametric immunophenotyping methods in fifteen NBAS-deficient patients to discover possible alterations in their immune system. RESULTS Our study revealed reduced absolute numbers of mature CD56dim natural killer (NK) cells. Notably, the residual NK cell population in NBAS-deficient patients exerted a lower potential for activation and degranulation in response to K562 target cells, suggesting an NK cell-intrinsic role for NBAS in the release of cytotoxic granules. NBAS-deficient NK cell activation and degranulation was normalized upon pre-activation by IL-2 in vitro, suggesting that functional impairment was reversible. In addition, we observed a reduced number of naïve B cells in the peripheral blood associated with hypogammaglobulinemia. CONCLUSION In summary, we demonstrate that pathogenic biallelic variants in NBAS are associated with dysfunctional NK cells as well as impaired adaptive humoral immunity.
Collapse
Affiliation(s)
- Dominic Lenz
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Jens Pahl
- Department of Immunobiochemistry, Mannheim Institute for Innate Immunoscience (MI3), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Fabian Hauck
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- German Centre for Infection Research (DZIF), Munich, Germany
- Munich Centre for Rare Diseases (M-ZSELMU), University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Seham Alameer
- Pediatric Department, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Meena Balasubramanian
- Sheffield Clinical Genetics Service, Sheffield Children's NHS Foundation Trust, Sheffield, UK
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Ivo Baric
- Department of Pediatrics, School of Medicine, University Hospital Center Zagreb and University of Zagreb, Zagreb, Croatia
| | - Nikolas Boy
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Joseph A Church
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, and Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ellen Crushell
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Anke Dick
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Felix Distelmaier
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jidnyasa Gujar
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Firenze, Italy
| | - Eberhard Lurz
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
| | - Bianca Peters
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Tobias Schwerd
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
| | - Daniele Serranti
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Firenze, Italy
| | - Stefan Kölker
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Christoph Klein
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- German Centre for Infection Research (DZIF), Munich, Germany
- Munich Centre for Rare Diseases (M-ZSELMU), University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Georg F Hoffmann
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Holger Prokisch
- Institute of Human Genetics, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum Munich, Neuherberg, Germany
| | - Johann Greil
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Heidelberg, Germany
| | - Adelheid Cerwenka
- Department of Immunobiochemistry, Mannheim Institute for Innate Immunoscience (MI3), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Thomas Giese
- Institute of Immunology and German Center for Infection Research (DZIF), Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Staufner
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| |
Collapse
|
35
|
高 伟, 石 茂, 张 海, 吴 春, 朱 继. [Relationship between marked hyperferritinemia and hemophagocytic lymphohistiocytosis]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:921-927. [PMID: 34650295 PMCID: PMC8517670 DOI: 10.19723/j.issn.1671-167x.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the relationship between marked hyperferritinemia (MHF) and hemophagocytic lymphohistiocytosis(HLH). METHODS The clinical data of 123 patients with MHF admitted to Peking University People's Hospital from January 2017 to September 2018 were collected, including demographics, baseline characteristics, signs and symptoms, blood routine, blood biochemistry, coagulation function parameters, such as prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib), d-dimer (D-D), fibrin degradation product (FDP), blood ferritin, natural killer (NK) cell activity, soluble interleukin (IL)-2 receptor and bone marrow examination. According to the diagnosis of HLH, the patients were divided into HLH group and non HLH group. The patients were divided into death group and survival group according to the 3-month follow-up results. The groups were compared and statistically analyzed. RESULTS In the 123 patients with MHF, the average age was (44.2±17.4) years with a male/female ratio of 1.3 ∶1. The most common causes were hematolo-gic malignancies, rheumatologic and inflammatory disorders, iron overload, and HLH. HLH was enriched as the ferritin increased, and the HLH ratios were 28.8%, 40.0%, 54.5%, 50.0%, 50.0% in ferritin value of 10 000-19 999, 20 000-29 999, 30 000-39 999, 40 000-49 999 μg/L, more than 50 000 μg/L respectively. There were 46 cases of HLH, among which 15 cases were secondary to malignancies, 14 cases secondary to rheumatologic disorders, 2 cases secondary to infection, and 15 cases with no clear precipitating cause. There were significant differences between the HLH group and non-HLH group in hepatomegaly, splenomegaly, lymphadenectasis, albumin (ALB), fibrinogen(Fib), P < 0.05, and no significant differences in age, gender, fever, disturbance of consciousness, ferritin level on presentation, maximum ferritin level, cytopenia in 2 or more cell lines, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL), triglyceride (TG), coagulation parameters (PT, APTT, D-D, FDP, exception of Fib), and mortality rate (P > 0.05). There were significant differences between the death group and survival group in disturbance of consciousness, platelet count, PT, TBIL, and DBIL (P < 0.05), but no significant differences in age, gender, fever, hepatomegaly, splenomegaly, lymphadenectasis, ferritin level on presentation, maximum ferritin level, neutrophils, hemoglobin, ALT, AST, ALB, TG, coagulation parameters (Fib, APTT, D-D, FDP, exception of PT) and the HLH ratio (P > 0.05). CONCLUSION HLH was enriched as the ferritin increased, but marked hyperferritinemia was not specific for HLH in adults.
Collapse
Affiliation(s)
- 伟波 高
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 茂静 石
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 海燕 张
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 春波 吴
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 继红 朱
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| |
Collapse
|
36
|
Imashuku S, Morimoto A, Ishii E. Virus-triggered secondary hemophagocytic lymphohistiocytosis. Acta Paediatr 2021; 110:2729-2736. [PMID: 34096649 DOI: 10.1111/apa.15973] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/18/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022]
Abstract
Primary (familial/hereditary) and secondary (non-familial/hereditary) hemophagocytic lymphohistiocytosis (HLH) are hyperinflammatory and hypercytokinemic syndromes. Secondary HLH includes infection- (eg viral/bacterial/fungal/parasitic) and non-infection- (eg collagen disease or malignancy) related diseases. Viral HLH is the major type among all age groups. Secondary viral HLH and primary HLH must be differentiated carefully because primary HLH can be associated with viral infection(s), and the outcome is dismal without a timely diagnosis and hematopoietic stem cell transplantation (HSCT). Epstein-Barr virus (EBV)-related HLH (EBV-HLH) is the most common type of viral HLH in childhood. For non-EBV-HLH, appropriate treatment of viral infection, followed by immunomodulatory agent(s) such as corticosteroids, intravenous immunoglobulin or cyclosporine A, is usually successful; however, recent SARS-CoV-2-related HLH may become life-threatening. EBV-HLH may occur heterogeneously associated with the primary infection, with chronic active EBV infection or with underlying primary HLH. Although immunomodulatory agent(s) are effective in the majority of EBV-HLH cases, management differs from that of non-EBV-HLH because severe and refractory cases may require etoposide-containing HLH-1994/2004 regimens or other experimental agents. The novel agent, emapalumab (an anti-IFN-γ monoclonal antibody) can be used to treat EBV-HLH cases to avoid the risk of secondary malignancy due to etoposide. Finally, HSCT is required for refractory EBV-HLH cases and can also be curative in some other cases.
Collapse
Affiliation(s)
- Shinsaku Imashuku
- Department of Laboratory Medicine Uji‐Tokushukai Medical Center Uji Kyoto Japan
| | - Akira Morimoto
- Department of Pediatrics Jichi Medical University School of Medicine Shimotsuke, Tochigi Japan
| | - Eiichi Ishii
- Director Imabari City Hospital Imabari, Ehime Japan
| |
Collapse
|
37
|
Kelkar MG, Bargir UA, Malik-Yadav R, Gupta M, Dalvi A, Jodhawat N, Shinde S, Madkaikar MR. CD8 + T Cells Exhibit an Exhausted Phenotype in Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2021; 41:1794-1803. [PMID: 34389889 DOI: 10.1007/s10875-021-01109-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/22/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome mainly caused by uncontrolled activation of antigen presenting cells and CD8 T cells. CD8 T cell exhaustion is a known phenomenon in chronic viral infections and cancer. However, the role of T cell exhaustion is not yet identified in HLH in the background of persistent inflammation. So, currently, we have characterized the CD8 T cells using flow cytometry to understand the phenomenon of exhaustion in these cells in HLH. METHODS We have comprehensively evaluated lymphocyte subsets and characterized CD8 T cells using immunophenotypic markers like PD1, TIM3, LAG3, Ki67, Granzyme B, etc. in a cohort of 21 HLH patients. Effector cytokine secretion and degranulation by CD8 T cells are also studied. RESULTS Our findings indicate skewed lymphocyte subsets and aberrantly activated CD8 T cells in HLH. CD8 T cells exhibit significantly increased expression of PD1, TIM3, and LAG3 prominently in primary HLH as compared to controls. PD1 + CD8 T cells express elevated levels of Granzyme B and Ki67. Moreover, CD8 T cells are hypofunctional as evidenced by significantly reduced cytokine secretion and compromised CD107a degranulation. CONCLUSION The study has revealed that CD8 + cytotoxic T lymphocytes from HLH patients exhibited high expression of exhaustion markers with overall impaired function. To the best of our understanding, this is the first report suggesting functional exhaustion of CD8 T cells in both primary and secondary HLH. Future studies to understand the association of exhaustion with disease outcome are needed for its probable therapeutic implementation.
Collapse
Affiliation(s)
- Madhura G Kelkar
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Umair Ahmad Bargir
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Reetika Malik-Yadav
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Maya Gupta
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Aparna Dalvi
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Neha Jodhawat
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Shweta Shinde
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India
| | - Manisha R Madkaikar
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology (NIIH), 13th Floor, NMS Building, KEM Hospital Campus, Parel, , Mumbai, 400012, India.
| |
Collapse
|
38
|
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: 41] [Impact Index Per Article: 13.7] [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
|
39
|
Shamriz O, Kumar D, Shim J, Briones M, Quarmyne MO, Chonat S, Lucas L, Edington H, White MH, Mahajan A, Park S, Chandrakasan S. T Cell-Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis (HLH) Occurs in Non-Asians and Is Associated with a T Cell Activation State that Is Comparable to Primary HLH. J Clin Immunol 2021; 41:1582-1596. [PMID: 34173902 PMCID: PMC8233186 DOI: 10.1007/s10875-021-01073-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/20/2021] [Indexed: 12/11/2022]
Abstract
Purpose T cell-Epstein-Barr virus–associated hemophagocytic lymphohistiocytosis (T cell-EBV-HLH) is prevalent in East Asia and has poor prognosis. Understanding of this disease is limited, and literature regarding prevalence in North America is scarce. Herein, we summarize our experience. Methods A retrospective analysis of T cell-EBV-HLH patients admitted to Children’s Healthcare of Atlanta (GA, USA) from 2010 to 2020 was conducted. Additional immune studies were completed in a subset of patients. Results We report 15 patients (10 months–19 years of age) diagnosed with T cell-EBV-HLH. Nine patients were Hispanic, and the majority did not have primary HLH (p-HLH) gene defects. Soluble interleukin-2 receptor levels in T cell-EBV-HLH were significantly higher than other forms of secondary-HLH but comparable to p-HLH, and it correlated with disease severity at presentation. Natural killer cell function was decreased in most patients despite a negative workup for p-HLH. Depending on disease severity, initial therapy included dexamethasone or dexamethasone and etoposide. Refractory patients were managed with blended regimens that included one or more of the following therapies: combination chemotherapy, alemtuzumab, emapalumab, and nivolumab. Rituximab did not appreciably decrease EBV viremia in most patients. Non-critically ill patients responded well to immunosuppressive therapy and are long-term survivors without undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Alemtuzumab resulted in inflammation flare in two of the three patients. Three patients underwent allogeneic HSCT, with disease relapse noted in one. At a median follow-up of 3 years, 10 of the 15 patients are alive. Conclusion T cell-EBV-HLH occurs in the USA among the non-Asian populations, especially in those who are Hispanic.
Collapse
Affiliation(s)
- Oded Shamriz
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak Kumar
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jenny Shim
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Maa-Ohui Quarmyne
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Center for Cancer and Blood Disorders, Phoenix Children's Hospital, AZ, Phoenix, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Laura Lucas
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Holly Edington
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael H White
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Advay Mahajan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sunita Park
- Department of Pathology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
| |
Collapse
|
40
|
Zhang Z, Wang S, Liang Q, Peng D. Progressive Heart Failure and Death as the Initial Manifestation of NK/T-Cell Lymphoma: A Case Report and Literature Review. Front Cardiovasc Med 2021; 8:685736. [PMID: 34250042 PMCID: PMC8264061 DOI: 10.3389/fcvm.2021.685736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022] Open
Abstract
Natural killer/T-cell (NK/T-cell) lymphoma is a rare-type non-Hodgkin lymphoma derived from NK cells or cytotoxic T cells. Here, we present a case of a 40-year-old woman who experienced quick-developed global heart failure and then was diagnosed with NK/T-cell lymphoma through lymphoid biopsy. Neither transthoracic echocardiography nor any radiological images detected a mass in her heart or pericardium. Elevated plasma troponin level and diffused patchy areas of gadolinium late enhancement on cardiac magnetic resonance were compatible with myocarditis. Considering the persistently elevated cytokine level, systemic inflammation symptoms, acute respiratory distress syndrome, and cardiac dysfunction, a cytokine storm secondary to NK/T-cell lymphoma was considered. Due to the refractory malignant arrhythmia, the patient died soon after being admitted to our hospital.
Collapse
Affiliation(s)
- Ziyu Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuai Wang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qingchun Liang
- Department of Pathology, The Second Xiangya Hospital, Central South Univerisity, Changsha, China
| | - Daoquan Peng
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
41
|
Ahmari AA, Alsmadi O, Sheereen A, Elamin T, Jabr A, El-Baik L, Alhissi S, Saud BA, Al-Awwami M, Fawaz IA, Ayas M, Siddiqui K, Hawwari A. Genetic and clinical characteristics of pediatric patients with familial hemophagocytic lymphohistiocytosis. Blood Res 2021; 56:86-101. [PMID: 34083498 PMCID: PMC8246041 DOI: 10.5045/br.2021.2020308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 05/02/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Abstract
Background Our study was designed to investigate the frequencies and distributions of familial hemophagocytic lymphohistiocytosis (FHL) associated genes in Saudi patients. Methods FHL associated gene screening was performed on 87 Saudi patients who were diagnosed with hemophagocytic lymphohistiocytosis (HLH) between 1995 and 2014. The clinical and biochemical profiles were also retrospectively captured and analyzed. Results Homozygous mutations and mono-allelic variants were identified in 66 (75.9%) and 3 (3.5%) of the study participants, respectively. STXBP2 was the most frequently mutated gene (36% of patients) and mutations in STXBP2 and STX11 accounted for 58% of all FHL cases and demonstrated a specific geographical pattern. Patients in the FHL group presented at a significantly younger age than those belonging to the unknown-genetics group (median, 3.9 vs. 9.4 mo; P=0.005). The presenting clinical features were similar among the various genetic groups and the 5-year overall survival (OS) was 55.4% with a 5.6 year median follow-up. Patients with PRF1 mutations had a significantly poorer 5-year OS (21.4%, P=0.008) and patients undergoing hematopoietic stem cell transplant (72.4%) had a significantly better 5-year OS (66.5% vs. 0%, P=0.001). Conclusion Our study revealed the predominance of the STXBP2 mutations in Saudi patients with FHL. A genetic diagnosis was possible in 80% of the cohort and our data showed improved survival in FHL patients who underwent hematopoietic stem cell transplant.
Collapse
Affiliation(s)
- Ali Al Ahmari
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Osama Alsmadi
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,Cell Therapy, Applied Genomics, King Hussein Cancer Center, Amman, Jordan
| | - Atia Sheereen
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Tanziel Elamin
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Amal Jabr
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Lina El-Baik
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Safa Alhissi
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Bandar Al Saud
- Department of Pediatric Allergy/Immunology, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Moheeb Al-Awwami
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Ibrahim Al Fawaz
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Mouhab Ayas
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Khawar Siddiqui
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Abbas Hawwari
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City Hospital, Al-Ahsa, Saudi Arabia
| |
Collapse
|
42
|
Chen Q, Liu S, Zhang K, Yu B, Zhang W, Zhang H, Chen X. Hsa-miR-372-5p regulates the NIMA related kinase 7 and IL-1β release in NK/T-cell lymphoma. Leuk Lymphoma 2021; 62:2648-2656. [PMID: 34080953 DOI: 10.1080/10428194.2021.1933472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Epstein-Barr virus (EBV) infection is prevalent and associated with distinct diseases including infectious mononucleosis (IM), chronic active EBV infection (CAEBV) and NK/T-cell lymphoma (NKTL). However, the specific roles of EBV in these diseases remain unclear. Here, the whole miRNA expression datasets derived from 7 IM, 6 CAEBV, and 3 NKTL biopsies were obtained. Homo sapiens microRNA-372-5p (Hsa-miR-372-5p) was upregulated in both CAEBV and NKTL patients. Overexpression of hsa-miR-372-5p altered the expression of over 100 proteins. In addition, hsa-miR-372-5p may target NIMA related kinase 7 to regulate NLRP3 inflammasome activation in host cell. Taken together, we reported different miRNA expression profiles in distinct EBV associated diseases, which provided novel insights to understand how host miRNAs contribute to the mechanism of EBV associated diseases. Hsa-miR-372-5p, as well as other differential expressed miRNA, might serve as potential targets in the therapy of various EBV associated diseases.
Collapse
Affiliation(s)
- Qi Chen
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Translational Medicine of Dermatology, Biomedical Research Institute, Shenzhen Peking University - The Hong Kong University of Science and Technology Medical Center, Shenzhen, China
| | - Shenglin Liu
- College of Biological and Food Engineering, Huaihua University, Huaihua, China.,Department of Dermatology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Kaoyuan Zhang
- Department of Dermatology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Bo Yu
- Department of Dermatology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Wei Zhang
- Shenzhen Key Laboratory for Translational Medicine of Dermatology, Biomedical Research Institute, Shenzhen Peking University - The Hong Kong University of Science and Technology Medical Center, Shenzhen, China
| | - Hongyu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xiaofan Chen
- Shenzhen Key Laboratory for Translational Medicine of Dermatology, Biomedical Research Institute, Shenzhen Peking University - The Hong Kong University of Science and Technology Medical Center, Shenzhen, China
| |
Collapse
|
43
|
Gao L, Yang L, Huang L, Xiao Y, Deng J, Zheng M, Luo H, Jiang L, Xiao M, Li C, Zhou J. Clinical and genetic features of Epstein-Barr virus-triggered late-onset primary hemophagocytic lymphohistiocytosis: Ten pedigrees study. Clin Transl Med 2021; 11:e393. [PMID: 34185399 PMCID: PMC8161514 DOI: 10.1002/ctm2.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Lili Gao
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Li Yang
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Liang Huang
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Yi Xiao
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Jinniu Deng
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Miao Zheng
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Hui Luo
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Lijun Jiang
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Min Xiao
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Chunrui Li
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Jianfeng Zhou
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| |
Collapse
|
44
|
Identification of germline variants in adults with hemophagocytic lymphohistiocytosis. Blood Adv 2021; 4:925-929. [PMID: 32150605 DOI: 10.1182/bloodadvances.2019001272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/29/2020] [Indexed: 12/13/2022] Open
Abstract
Key Points
Some germline variants are predicted to disrupt protein function in HLH-associated genes. Such variants are neither enriched in adult-onset HLH nor associated with specific clinical or laboratory features of HLH.
Collapse
|
45
|
Iizuka H, Mori Y, Iwao N, Koike M, Noguchi M. Hemophagocytic lymphohistiocytosis associated with Epstein-Barr virus-positive diffuse large B-cell lymphoma, NOS of bone marrow-liver-spleen type: an autopsy case report. J Clin Exp Hematop 2021; 61:102-108. [PMID: 33994430 PMCID: PMC8265493 DOI: 10.3960/jslrt.20053] [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: 12/12/2022] Open
Abstract
Lymphoma-associated hemophagocytic lymphohistiocytosis (HLH) has a significantly poor prognosis among secondary HLH. We describe the rare case of a 74-year-old female with secondary HLH presenting with a rapidly fatal course. Post-mortem examination revealed Epstein-Barr virus (EBV) -positive diffuse large B-cell lymphoma (DLBCL). We were unable to make a definite antemortem diagnosis because the patient did not exhibit lymphadenopathy and bone marrow biopsy demonstrated hemophagocytosis without evidence of lymphoma. She died of multiple organ failure on the twelfth day of hospitalization despite a temporary response to steroids. Autopsy revealed diffuse lymphoma cell infiltration of the bone marrow, liver and spleen, suggesting “bone marrow-liver-spleen” (BLS)-type large B-cell lymphoma (LBCL). BLS-type LBCL is a rare and clinically aggressive lymphoma, usually associated with fever, cytopenia and HLH. The disease has a high mortality rate due to the delay in diagnosis and a highly aggressive clinical course. Further studies are required to improve our understanding of this rare extranodal DLBCL.
Collapse
Affiliation(s)
- Hiroko Iizuka
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan.,Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Yosuke Mori
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan.,Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Noriaki Iwao
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Michiaki Koike
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| |
Collapse
|
46
|
Santana Quintana A, Valga F, Vega Díaz N, Fernández JM, Quevedo Reina JC, Rincón Tirado M, Aladro Escribano S, Rodríguez Pérez JC. Not all cytokin storms are due to COVID-19: Hemophagotic syndrome with renal involvement secondary to extranasal lymphoma and Epstein-Barr virus. A case report during the pandemic. Nefrologia 2021; 41:347-349. [PMID: 36166250 PMCID: PMC8408657 DOI: 10.1016/j.nefroe.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
- Adonay Santana Quintana
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain.
| | - Francisco Valga
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain
| | - Nicanor Vega Díaz
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain
| | - Juan Manuel Fernández
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain
| | - Juan Carlos Quevedo Reina
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain
| | - Marian Rincón Tirado
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain
| | - Sara Aladro Escribano
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Canarias, Spain
| | | |
Collapse
|
47
|
Di Giorgio A, Bartolini E, Calvo PL, Cananzi M, Cirillo F, Della Corte C, Dionisi-Vici C, Indolfi G, Iorio R, Maggiore G, Mandato C, Nebbia G, Nicastro E, Pinon M, Ranucci G, Sciveres M, Vajro P, D'Antiga L. Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group. Dig Liver Dis 2021; 53:545-557. [PMID: 33775575 DOI: 10.1016/j.dld.2021.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.
Collapse
Affiliation(s)
- A Di Giorgio
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy.
| | - E Bartolini
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - P L Calvo
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - M Cananzi
- Unit of Pediatric Gastroenterology and Hepatology, Dpt. of Women's and Children's Health, University Hospital of Padova, Italy
| | - F Cirillo
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - C Della Corte
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - G Indolfi
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - R Iorio
- Paediatric Liver Unit, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - G Maggiore
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - G Nebbia
- Pediatric Liver Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Nicastro
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
| | - M Pinon
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - G Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - M Sciveres
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - P Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" Section of Pediatrics, University of Salerno, Baronissi (Salerno), Italy
| | - L D'Antiga
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
| |
Collapse
|
48
|
Khare N, Jinkala SR, Kanungo S. Performance of HScore in Reactive Hemophagocytic Lymphohistiocytosis. Indian J Hematol Blood Transfus 2021; 37:256-263. [PMID: 33867732 PMCID: PMC8012436 DOI: 10.1007/s12288-020-01342-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/26/2020] [Indexed: 01/07/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life threatening systemic hyperinflammatory disorder that leads to multiple organ damage. The most widely used diagnostic guidelines are the HLH 2004 guidelines proposed by the Histiocyte society. Recently, Fardet et al. has proposed a Scoring system, "HScore" for diagnosis of reactive HLH. To test the performance of "HScore" in diagnosis of reactive HLH and compare the credibility of the same with the existing gold standard 2004 guidelines in a cohort of Indian patients. This was a descriptive study of cases referred to the department of Pathology for bone marrow examination with suspicion or diagnosis of HLH from Jan 2015 to June 2017. The clinical records of these patients were analysed and diagnosed as positive and negative for HLH using the HLH 2004 guidelines and HScore, the scoring system developed by Fardet et al. Fifty cases fulfilled the inclusion criteria. The variables fever, hepato and /or splenomegaly, high triglyceride levels and marrow hemophagocytosis are highly significant to predict an individuals risk of HLH. We propose a cut-off of ≥ 166 for the diagnosis of HLH by using HScore. If 4 of the 7 criteria are fulfilled by HLH 2004 guidelines, there is an 80% probability of having HLH by HScore. The HScore is less restrictive in confirming a diagnosis of HLH compared to the HLH 2004 guidelines. HScore is a simple, and cost effective tool for diagnosis of reactive HLH. The higher the HScore, more is the probability of HLH.
Collapse
Affiliation(s)
- Neerav Khare
- VI Semester MBBS, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| | - Sree Rekha Jinkala
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| | - Srikanta Kanungo
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| |
Collapse
|
49
|
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
|
50
|
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
|