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Marwah V, Choudhary R, Kumar TA, Sharma M. Haemophagocytic lymphohistiocytosis post-ChAdOx1 nCoV-19 vaccine: A rare case. THE NATIONAL MEDICAL JOURNAL OF INDIA 2024; 37:90-92. [PMID: 39222526 DOI: 10.25259/nmji_ms_466_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
The severe acute respiratory syndrome coronavirus 2 pandemic started in December 2019, spread like wildfire and took an immense toll on human life. ChAdOx1 nCoV-19 vaccine was used worldwide for the prevention of Covid-19. Covid-19 has been implicated in the causation of severe haemophagocytic lymphohistiocytosis (HLH) syndrome. However, the same has not been reported with ChAdOx1 nCoV-19 vaccine in the literature. We report a young man who developed secondary HLH post-ChAdOx1 nCoV-19 vaccination.
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Affiliation(s)
- Vikas Marwah
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Robin Choudhary
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Tentu Ajai Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Manish Sharma
- Department of Pathology, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
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2
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Stoian M, Procopiescu B, Șeitan S, Scarlat G. Post-COVID-19 syndrome: Insights into a novel post-infectious systemic disorder. J Med Life 2023; 16:195-202. [PMID: 36937488 PMCID: PMC10015558 DOI: 10.25122/jml-2022-0329] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/17/2023] [Indexed: 03/21/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is currently considered a complex systemic infectious and inflammatory disease, determined by the infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the cause of one of the most important epidemiological phenomena in the last century - the COVID-19 pandemic. This infectious-inflammatory disease may generate a wide range of clinical manifestations and biological modifications, explained by the ubiquitous nature of the SARS-CoV-2 receptors, represented by the angiotensin-converting enzyme-2 (ACE-2), and by the host's violent immune and proinflammatory reaction to the viral infection. These manifestations include immunological disturbances, which, according to certain clinical findings, may persist post-infection, in the form of a presumed systemic inflammatory entity, defined by several clinical concepts with a common pathological significance: post-COVID-19 multisystem (or systemic) inflammatory syndrome, post-COVID syndrome or long-COVID. Although the pathophysiological mechanisms of the post-COVID-19 syndrome are elusive at the present moment, there are currently several studies that describe a systemic inflammatory or autoimmune phenomenon following the remission of the COVID-19 infection in some patients, which suggests the existence of molecular and cellular immune abnormalities, most probably due to the host's initial violent immune response to the viral infection, in the form of three overlapping entities: secondary hemophagocytic lymph histiocytosis (HLH), macrophage activation syndrome (MAS) and cytokine release syndrome (CRS). Thus, this is reminiscent of different classic autoimmune diseases, in which various infections are risk factors in developing the autoimmune process.
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Affiliation(s)
- Marilena Stoian
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Corresponding Author: Marilena Stoian, Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. E-mail:
| | - Bianca Procopiescu
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Silviu Șeitan
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Gabriel Scarlat
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
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3
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Ioannou M, Zacharouli K, Doukas SG, Diamantidis MD, Tsangari V, Karakousis K, Koukoulis GK, Vageli DP. Hemophagocytic lymphohistiocytosis diagnosed by bone marrow trephine biopsy in living post-COVID-19 patients: case report and mini-review. J Mol Histol 2022; 53:753-762. [PMID: 35699822 PMCID: PMC9192937 DOI: 10.1007/s10735-022-10088-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/31/2022] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) constitutes a life-threatening inflammatory syndrome. Postmortem histological findings of bone marrow (BM) from COVID-19 patients showed histiocytosis and hemophagocytosis and supported the hypothesis that secondary HLH (sHLH) may be triggered by SARS-CoV-2 infection. However, there are a limited number of sHLH cases in which trephine has been performed in living post-COVID-19 patients. Here we present a recent case and a mini-review of sHLH diagnosed by trephine biopsy in living patients after COVID-19. An 81-year-old man with a past medical history of hypertension, diabetes, ischemic stroke, was referred to the hospital to evaluate leukocytosis, pyuria, and elevation of inflammatory markers four weeks after recovering from COVID-19. Computed tomography of the abdomen did not reveal focal signs of infection or hepatosplenomegaly. The patient received intravenous meropenem and two packed red blood cell units. Leukocytes and C-reactive protein were gradually decreased. A BM biopsy was performed and the patient was discharged on cefixime. BM smear revealed severe anemia, lymphopenia, and dysplastic morphologic findings of erythroblasts, neutrophils, and megakaryocytes. Trephine biopsy revealed hypercellular marrow dyserythropoiesis, plasmacytosis, lymphocytosis, histiocytosis, hemophagocytosis, and the absence of granulomas or carcinoma. Immunohistochemistry documented a mixed population of T lymphocytes (CD3+) and B lymphocytes (CD20+). Strong positivity for CD68 confirmed histiocytosis. CD138 κ, λ staining proved polyclonal plasmacytosis. Perl's staining showed excess hemosiderin deposits. Based on our findings, we document sHLH in trephine BM biopsy of a living post-COVID-19 patient and persistent leukocytosis, underscoring the diagnostic value of trephine biopsy in preventing life-threatening conditions such as COVID-19.
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Affiliation(s)
- Maria Ioannou
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Konstantina Zacharouli
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Sotirios G Doukas
- Department of Toxicology Department of Forensic Sciences and Laboratory of Toxicology, Medical School, University of Crete, 71003, Heraklion, Greece
- Department of Medicine, Rutgers/Saint Peter's University Hospital, 08901, New Brunswick, NJ, USA
| | - Michael D Diamantidis
- Thalassemia and Sickle Cell Disease Unit, Department of Hematology, General Hospital of Larissa, Larissa, Greece
| | - Vaya Tsangari
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | | | - George K Koukoulis
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Dimitra P Vageli
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece.
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Gautam S, Sharma G, Singla S, Garg S. Case Report: Secondary Hemophagocytic Lymphohistiocytosis (sHLH) and Candida auris Fungemia in Post-acute COVID-19 Syndrome: A Clinical Challenge. Front Med (Lausanne) 2022; 9:835421. [PMID: 35783658 PMCID: PMC9247387 DOI: 10.3389/fmed.2022.835421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/28/2022] [Indexed: 12/21/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes a disease (COVID-19) with multisystem involvement. The world is now entering a phase of post-COVID-19 manifestations in this pandemic. Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory event triggered by viral infections, including SARS-CoV-2. Both Multisystem Inflammatory Syndrome-Adults (MIS-A) and Cytokine Storm Syndrome (CSS) are considered close differentials of sHLH and add to the spectrum of Post-acute COVID-19 syndrome (PACS). In this report, we presented the case of a middle-aged Asian man who was initially discharged upon recovery from severe COVID-19 infection after 17 days of hospitalization to a private institute and later came to our hospital 13 days post-discharge. Here, he was diagnosed with sHLH, occurring as an extension of CSS, with delayed presentation falling within the spectrum of PACS. The diagnosis of sHLH was made holistically with the HLH-2004 criteria. Our patient initially responded to intravenous immunoglobulin (IVIG) and dexamethasone, later complicated by disseminated Candida auris infection and had a fatal outcome. Though many cases of HLH during active COVID-19 and a few cases post COVID-19 recovery have been reported, based on H-score, which has limitations as a diagnostic tool. We report the first case report of post-COVID-19 sHLH using the HLH-2004 criteria, complicated by disseminated Candidemia, emphasizing that the care of patients with COVID-19 does not conclude at the time of hospital discharge. We highlight the importance of surveillance in the post-COVID phase for early detection of sHLH which may predispose to fatal opportunistic infections (OIs).
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Affiliation(s)
- Sachin Gautam
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
| | - Gaurav Sharma
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
| | - Sumeet Singla
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
| | - Sandeep Garg
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
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Bandaru SS, Capace A, Busa V, Williams A. Secondary Hemophagocytic Lymphohistiocytosis in a Post-COVID-19 Patient. Cureus 2022; 14:e22620. [PMID: 35317032 PMCID: PMC8934199 DOI: 10.7759/cureus.22620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition caused by excessive immune system activation. HLH can be primary or secondary. Primary HLH is commonly seen in children with underlying genetic mutations, while secondary HLH can be seen at any age. It is usually triggered by inciting factors such as viral infections, patients with underlying rheumatological disease, or malignancies. It has very poor prognosis if left untreated, with survival of only a few months. While there have been around 100 cases of HLH reported during the acute phase of COVID-19 infection, very few post-COVID-19 HLH cases have been reported, only around 35 cases. Here we report a case of a 20-year-old Caucasian male who presented eight weeks after COVID-19 infection with extreme fatigue, fever, lab work concerning for HLH, and a high H score indicating a high probability of HLH. Early identification of HLH following COVID-19 recovery would allow for timely management of the condition.
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Dandu H, Yadav G, Malhotra HS, Pandey S, Sachu R, Dubey K. Hemophagocytic histiocytosis in severe SARS-CoV-2 infection: A bone marrow study. Int J Lab Hematol 2021; 43:1291-1301. [PMID: 34086418 PMCID: PMC8239926 DOI: 10.1111/ijlh.13619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The clinical and laboratory features of severe COVID-19 infection overlap with those of hemophagocytic lymphohistiocytosis (HLH), a hyperinflammatory disorder often associated with several viral infections. The clinical syndrome of HLH encompasses fever, organomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, raised transaminases, hypofibrinogenemia, absent natural killer (NK) cell activity, increased soluble CD25 and hemophagocytic lymphohistiocytosis in bone marrow, spleen, and lymph nodes. METHODS We analyzed clinicopathological and laboratory features of thirteen patients with severe COVID-19 infection suspected to have HLH and found to have hemophagocytic histiocytosis on bone marrow examination (BME). RESULTS Five of thirteen (38.46%) patients fulfilled five of eight HLH 2004 criteria and/or had a H-score ≥169. Three (23.08%) satisfied four of eight and remainder five (38.46%) satisfied three of eight HLH 2004 criteria. Fever, raised serum ferritin (13/13, 100%), transaminases (9/13, 69.23%), triglycerides (4/13, 30.76%), cytopenias (5/13, 38.46%), hypofibrinogenemia (2/13, 15.38%), and organomegaly (1/13, 7.69%) were observed in our patients. BME showed hemophagocytic histiocytosis without lymphocytosis in all. Contrary to HLH, lymphocytopenia (11/13, 84.61%), leukocytosis (7/13, 53.84%), neutrophilia (7/13, 53.84%), and hyperfibrinogenemia (7/13, 53.84%) were observed. Serum CRP, LDH, and plasma D-dimer were elevated in all, while serum albumin was decreased in 12 of 13 (92.3%) patients. Five patients recovered with high-dose pulsed corticosteroid therapy. CONCLUSION The immune response associated with severe COVID-19 infection is similar to HLH with few differences. HLH should be suspected in severe COVID-19 infection although all patients may not fulfill required HLH diagnostic criteria. BME should be done in suspected cases so that appropriate therapy may be initiated early.
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Affiliation(s)
- Himanshu Dandu
- Department of Internal MedicineKing George’s Medical UniversityLucknowIndia
| | - Geeta Yadav
- Department of PathologyKing George’s Medical UniversityLucknowIndia
| | | | - Saurabh Pandey
- Department of Internal MedicineKing George’s Medical UniversityLucknowIndia
| | - Ruovinuo Sachu
- Department of PathologyKing George’s Medical UniversityLucknowIndia
| | - Kinjalk Dubey
- Department of Internal MedicineKing George’s Medical UniversityLucknowIndia
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Lacinel Gurlevik S, Aksu T, Ozen S, Kesici S, Gumruk F, Ozsurekci Y. Hemophagocytosis in bone marrow aspirates in multisystem inflammatory syndrome in children. Pediatr Blood Cancer 2021; 68:e28931. [PMID: 33619863 DOI: 10.1002/pbc.28931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Sibel Lacinel Gurlevik
- Department of Pediatric Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tekin Aksu
- Department of Pediatric Hematology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Fatma Gumruk
- Department of Pediatric Hematology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yasemin Ozsurekci
- Department of Pediatric Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Verma DP, Dandu H, Yadav G, Verma SP. Complicated case of COVID-19 disease with overlapping features of thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. BMJ Case Rep 2021; 14:14/5/e242202. [PMID: 34011641 PMCID: PMC8137254 DOI: 10.1136/bcr-2021-242202] [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] [Indexed: 12/18/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis has been reported as an uncommon complication of severe COVID-19 disease while thrombotic thrombocytopenic purpura has been rarely reported. Here, we are reporting a 21-year-old man who developed a combination of these complications during the hospital stay in the post-COVID-19 recovery period. He presented with fever and bilateral COVID-19-related pneumonia requiring invasive ventilation. His hospital course was complicated by the development of pneumothorax, ventilator-associated pneumonia, thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. He received remdesivir, IVIG, steroid, fresh frozen plasma and supportive care but had a fatal outcome.
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Affiliation(s)
- Durga Prasad Verma
- Clinical Hematology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Himanshu Dandu
- Medicine, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Geeta Yadav
- Pathology, King Georges Medical University, Lucknow, Uttar Pradesh, India
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Iovino L, Thur LA, Gnjatic S, Chapuis A, Milano F, Hill JA. Shared inflammatory pathways and therapeutic strategies in COVID-19 and cancer immunotherapy. J Immunother Cancer 2021; 9:e002392. [PMID: 33986127 PMCID: PMC8126446 DOI: 10.1136/jitc-2021-002392] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 01/28/2023] Open
Abstract
COVID-19, the syndrome caused by the infection with SARS-CoV-2 coronavirus, is characterized, in its severe form, by interstitial diffuse pneumonitis and acute respiratory distress syndrome (ARDS). ARDS and systemic manifestations of COVID-19 are mainly due to an exaggerated immune response triggered by the viral infection. Cytokine release syndrome (CRS), an inflammatory syndrome characterized by elevated levels of circulating cytokines, and endothelial dysfunction are systemic manifestations of COVID-19. CRS is also an adverse event of immunotherapy (IMTX), the treatment of diseases using drugs, cells, and antibodies to stimulate or suppress the immune system. Graft-versus-host disease complications after an allogeneic stem cell transplant, toxicity after the infusion of chimeric antigen receptor-T cell therapy and monoclonal antibodies can all lead to CRS. It is hypothesized that anti-inflammatory drugs used for treatment of CRS in IMTX may be useful in reducing the mortality in COVID-19, whereas IMTX itself may help in ameliorating effects of SARS-CoV-2 infection. In this paper, we focused on the potential shared mechanisms and differences between COVID-19 and IMTX-related toxicities. We performed a systematic review of the clinical trials testing anti-inflammatory therapies and of the data published from prospective trials. Preliminary evidence suggests there might be a benefit in targeting the cytokines involved in the pathogenesis of COVID-19, especially by inhibiting the interleukin-6 pathway. Many other approaches based on novel drugs and cell therapies are currently under investigation and may lead to a reduction in hospitalization and mortality due to COVID-19.
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Affiliation(s)
- Lorenzo Iovino
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Laurel A Thur
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sacha Gnjatic
- Medicine-Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aude Chapuis
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua A Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Naous E, Nassani BM, Yaghi C, Nasr F, Medlej R. Hemophagocytic lymphohistiocytosis, a new cause of death during 'post-acute COVID-19 syndrome?' A case report. J Hematop 2021; 14:229-233. [PMID: 33897909 PMCID: PMC8057656 DOI: 10.1007/s12308-021-00452-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/14/2021] [Indexed: 12/13/2022] Open
Abstract
'Post-acute coronavirus disease 2019 (COVID-19) syndrome' is a new term that was coined to describe a constellation of persistent symptoms and new complications following recovery from COVID-19 initial illness. Identifying post-COVID-19 complications is crucial for early diagnosis and subsequent initiation of therapies to ensure more favorable outcomes. Severe COVID-19-related hemophagocytic lymphohistiocytosis (HLH) has been previously described during the acute phase of the infection. It is characterized by hyperinflammation, multi-organ involvement, and hemophagocytosis. We report the case of a 69-year-old woman who presented, two weeks after recovery from COVID-19, with hyperosmolar state and high inflammatory markers. Bone marrow aspirate, flow cytometry, extensive viral panel and total body scan were performed. Review of bone marrow aspirate smear showed hemophagocytosis. Flow cytometry, viral panel, and total body scan were normal. The diagnosis of post COVID-19-related HLH was made. Unfortunately, the patient died despite adequate treatment. To our knowledge, this is the first case establishing a high probability of COVID-19-related HLH given its occurrence two weeks following a documented biological and clinical recovery. Awareness and early recognition of HLH features following COVID-19 recovery should prompt timely initiation of therapy.
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Affiliation(s)
- Elie Naous
- Department of Internal Medicine, Endocrinology Division, Hotel Dieu de France Hospital, Beirut, Lebanon
- Saint Joseph University, Beirut, Lebanon
| | - Bertha-Maria Nassani
- Department of Internal Medicine, Endocrinology Division, Hotel Dieu de France Hospital, Beirut, Lebanon
- Saint Joseph University, Beirut, Lebanon
| | - Cesar Yaghi
- Saint Joseph University, Beirut, Lebanon
- Department of Internal Medicine, Gastroenterology Division, Hotel Dieu de France, Beirut, Lebanon
| | - Fadi Nasr
- Saint Joseph University, Beirut, Lebanon
- Department of Internal Medicine, Hematology Oncology Division, Hotel Dieu de France, Beirut, Lebanon
| | - Rita Medlej
- Department of Internal Medicine, Endocrinology Division, Hotel Dieu de France Hospital, Beirut, Lebanon
- Saint Joseph University, Beirut, Lebanon
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Retamozo S, Brito-Zerón P, Sisó-Almirall A, Flores-Chávez A, Soto-Cárdenas MJ, Ramos-Casals M. Haemophagocytic syndrome and COVID-19. Clin Rheumatol 2021; 40:1233-1244. [PMID: 33389315 PMCID: PMC7778844 DOI: 10.1007/s10067-020-05569-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022]
Abstract
Primary and secondary haemophagocytic lymphohistiocytosis (HLH) are hyperferritinaemic hyperinflammatory syndromes with a common terminal pathway triggered by different etiopathogenetic factors. HLH is characterised by a decreased capacity of interferon gamma production with an activated NK phenotype profile similar to other hyperinflammatory syndromes. Viruses are closely linked to the development of HLH as infectious triggers, and the break of tolerance to self-antigens is considered a critical mechanism involved in the development of immune-mediated conditions triggered by viral infections. Emerging studies in patients with COVID-19 are suggesting a key role of monocytes/macrophages in the pathogenesis of this viral infection, and there is a significant overlap between several features reported in severe COVID-19 and the features included in the HLH-2004 diagnostic criteria. Therefore, SARS-Cov-2, as other respiratory viruses, may also be considered a potential etiological trigger of HLH. The frequency of HLH in adult patients with severe COVID-19 is lower than 5%, although this figure could be underestimated considering that most reported cases lacked information about some specific criteria (mainly the histopathological criteria and the measurement of NK cell function and sCD25 levels). Because HLH is a multi-organ syndrome, the diagnostic approach in a patient with severe COVID-19 in whom HLH is suspected must be carried out in a syndromic and holistic way, and not in the light of isolated clinical or laboratory features. In COVID-19 patients presenting with persistent high fever, progressive pancytopenia, and hepatosplenic involvement, together with the characteristic triad of laboratory abnormalities (hyperferritinaemia, hypertriglyceridaemia, and hypofibrinogenaemia), the suspicion of HLH is high, and the diagnostic workup must be completed with specific immunological and histopathological studies.
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Affiliation(s)
- Soledad Retamozo
- Instituto Modelo de Cardiología Privado S.R.L- Córdoba - Argentina, Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
| | - Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain
| | - Antoni Sisó-Almirall
- Grup Tranversal de Recerca en Atenció Primària, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre d'Atenció Primària Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerre (CAPSBE), Barcelona, Spain
| | | | - María-José Soto-Cárdenas
- Department of Internal Medicine, Hospital Universitario Puerta del Mar, Cádiz, University of Cadiz, Cadiz, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain.
- Department of Medicine, University of Barcelona, Barcelona, Spain.
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
- Servei de Malalties Autoimmunes Sistèmiques, Hospital Clínic, C/Villarroel, 170, 08036, Barcelona, Spain.
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12
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Michaelis S, Pichler A, Stelzer I, Tinchon C, Enko D. Concomitant immune thrombocytopenia and bone marrow hemophagocytosis in a patient with SARS-CoV-2. Clin Chem Lab Med 2021; 59:e358-e361. [PMID: 33721917 DOI: 10.1515/cclm-2021-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Simon Michaelis
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Hochsteiermark, Leoben, Austria
| | - Angelika Pichler
- Department of Hemato-Oncology, General Hospital Hochsteiermark, Leoben, Austria
| | - Ingeborg Stelzer
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Hochsteiermark, Leoben, Austria
| | - Christoph Tinchon
- Department of Hemato-Oncology, General Hospital Hochsteiermark, Leoben, Austria
| | - Dietmar Enko
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Hochsteiermark, Leoben, Austria.,Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
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