1
|
Simard C, Tardif ML. Hemophagocytic lymphohistiocytosis in pregnancy evolving towards fulminant hepatitis. Obstet Med 2022; 15:208-211. [PMID: 36262816 PMCID: PMC9574453 DOI: 10.1177/1753495x21999914] [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: 11/19/2020] [Revised: 11/19/2020] [Accepted: 02/09/2021] [Indexed: 09/03/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis is a rare disorder, especially in pregnancy, characterized by excessive immune activation leading to hemophagocytic activity. Case Report A 34-year-old woman presented at 31 weeks' gestation with fever, cytopenias, hyperferritinemia and fulminant hepatitis. Bone marrow biopsy was non-contributory, and no trigger was identified. Liver biopsy confirmed the diagnosis of hemophagocytic lymphohistiocytosis, and she received dexamethasone and etoposide, which was changed to anakinra to allow breastfeeding. Prompt diagnosis and treatment of hemophagocytic lymphohistiocytosis is crucial to the survival of pregnant women, but no consensus exists regarding the most appropriate therapy during pregnancy. Conclusion Hemophagocytic lymphohistiocytosis is life-threatening and associated with significant morbidity and mortality. Important treatment considerations in pregnancy include maternal health, fetal prematurity and treatment toxicity. Anakinra has been successfully used in pregnancy and provides a promising alternative.
Collapse
Affiliation(s)
- Camille Simard
- Department of Medicine, McGill University, Montreal,
Canada
| | - Marie-Lou Tardif
- Division of Obstetric Medicine, Department of Obstetrics and
Gynecology, CHU Sainte-Justine, Montreal, Canada
- Department of Medicine, Université de Montréal, Montreal,
Canada
| |
Collapse
|
2
|
Rolsdorph LÅ, Mosevoll KA, Helgeland L, Reikvam H. Concomitant Hemophagocytic Lymphohistiocytosis and Cytomegalovirus Disease: A Case Based Systemic Review. Front Med (Lausanne) 2022; 9:819465. [PMID: 35514747 PMCID: PMC9063453 DOI: 10.3389/fmed.2022.819465] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/25/2022] [Indexed: 12/25/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an immune mediated life-threatening condition. It is driven by an overactivation of the immune system and causes inflammatory tissue damage potentially leading to organ failure and death. Primary HLH is caused by genetic mutations, while secondary HLH is triggered by external factors. Viral infections are a well-known cause of secondary HLH. Cytomegalovirus (CMV) is a virus in the herpes family known to cause HLH in rare cases. Methods We report a recent case of CMV-induced HLH, followed by a systematic review of described cases of this rare disease entity, through a structured search in the medical database PubMed. All articles were assessed on a predetermined set of inclusion criteria. Results A total of 74 patients (age > 18 years) with CMV-related HLH were identified, 29 men, 42 women, and three patients with unspecified gender. Median age was 37.5 years (range 18-80). Sixty-six patients (88%) had one or more comorbid conditions and 22 patients (30%) had inflammatory bowel disease (IBD), the most frequent comorbidity. Forty patients (54%) received some form of immunomodulating treatment prior to HLH development. The general treatment approach was in general dual, consisting of antiviral treatment and specific immunomodulating HLH treatment approaches. Treatment outcome was at 77% survival, while 23% had fatal outcome. Conclusion The findings highlight the importance of early diagnostic work up and treatment intervention. Ability to recognize the characteristic clinical traits and perform specific HLH diagnostic workup are key factors to ensure targeted diagnostic work and treatment intervention for this patient group.
Collapse
Affiliation(s)
- Linn Åsholt Rolsdorph
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Knut Anders Mosevoll
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Helgeland
- Department of Medical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
3
|
Fávero Vanraes L, Beckers V, Van Berkel K, Gucciardo L, Faron G. Haemophagocytic lymphohistiocytosis during pregnancy: a case presentation and literature review. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disorder of the immune system that typically occurs in the paediatric population. Diagnosing this rare disease in the adult population is challenging, particularly during pregnancy.
Case presentation
We present a case of a gravid patient developing HLH at week 13 of gestation undergoing a medical termination of pregnancy at 27 weeks due to anhydramnios and associated stopped foetal growth.
Conclusions
Disease triggers could vary from a simple viral infection to the pregnancy as such causing the disorder. Treatment should benefit the mother and limit the foetal harm.
Collapse
Affiliation(s)
- Larissa Fávero Vanraes
- Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Veerle Beckers
- Division of Haematology, Department of Internal Medicine , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Kim Van Berkel
- Department of Medical Genetics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Leonardo Gucciardo
- Division of Prenatal Medicine and Obstetrics, Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Gilles Faron
- Division of Prenatal Medicine and Obstetrics, Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| |
Collapse
|
4
|
Liu C, Gao J, Liu J. Management of hemophagocytic lymphohistiocytosis in pregnancy: Case series study and literature review. J Obstet Gynaecol Res 2022; 48:610-620. [PMID: 34978123 PMCID: PMC9303886 DOI: 10.1111/jog.15133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
Aim The diagnosis and treatment of hemophagocytic lymphohistiocytosis (HLH) in pregnancy is challenging due to its rarity. We aim to analyze and summarize the clinical characteristics of HLH in pregnancy, and to discuss effective diagnostic and treatment options. Methods Thirteen patients with HLH during pregnancy who were diagnosed and treated at the Peking Union Medical College Hospital of the Chinese Academy of Medical Sciences from January 2000 to December 2019 were studied retrospectively. We collected data on treatment regimens and on maternal and pregnancy outcomes. Results All patients had a singleton pregnancy, with a median age of 28 years (range, 22–33 years) and a median gestational age of 23 weeks (7–36 weeks). Twelve patients received corticosteroids, and four patients (with/without intravenous immunoglobulin) showed a curative effect. Two patients who were treated with dexamethasone and etoposide after termination of pregnancy achieved complete remission. Two patients attained remission after termination of pregnancy. Four pregnant women died, and the mortality rate was 30.8% (4/13). Fetal or neonatal death up to 1 week after delivery occurred in eight (61.5%) pregnancies. Conclusions Early diagnosis and treatment are important for maternal survival, and corticosteroids are the first choice for most patients with HLH during pregnancy. For patients who do not respond to corticosteroids, etoposide and termination of pregnancy may be life‐saving.
Collapse
Affiliation(s)
- Congcong Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
5
|
Takahashi M, Makino S, Iizuka H, Noguchi M, Yoshida K. Chronic active Epstein-Barr virus-associated secondary hemophagocytic lymphohistiocytosis in pregnancy: a case report. BMC Pregnancy Childbirth 2021; 21:681. [PMID: 34620104 PMCID: PMC8495184 DOI: 10.1186/s12884-021-04150-4] [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] [Received: 07/28/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare and fatal disease characterized by uncontrolled immune cell activation that can lead to a cytokine storm. Unfortunately, this condition can occur even during pregnancy, threatening both maternal and fetal lives. CASE PRESENTATION A 23-year-old nulliparous woman at 26 weeks of gestation presented with continuous fever, coughing, and sore throat. Upon arrival at our hospital, her temperature was >38°C and laboratory findings indicated cytopenia (neutrophil count, 779/μL; hemoglobin level, 10.2 g/dL; platelet count, 29,000/μL), elevated ferritin level (1,308 ng/mL), and elevated soluble interleukin-2 receptor level (11,200 U/mL). Computed tomography showed marked splenomegaly. Bone marrow examination revealed hemophagocytosis, and blood examination showed a plasma Epstein-Barr virus (EBV) DNA level of 8.9 × 105 copies/μg. The monoclonal proliferation of EBV-infected T cells was confirmed by Southern blotting, and the patient was diagnosed with chronic active EBV-associated sHLH and T-cell lymphoproliferative disease. Immediately after admission, the patient's condition suddenly deteriorated. She developed shock and disseminated intravascular coagulation, requiring endotracheal intubation along with methylprednisolone pulse and etoposide therapy. Although the patient recovered, she delivered a stillborn baby. After delivery, she was treated with reduced-dose dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC) and steroid (dexamethasone), methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) chemotherapies. Five months after diagnosis, she received human leukocyte antigen-haploidentical allogeneic bone marrow transplantation from her sister. She remains in remission for 5 months from the time of transplantation to the present. CONCLUSIONS sHLH, which may cause maternal and fetal death, should be carefully considered in critically ill pregnant women, particularly those presenting with continuous fever and cytopenia.
Collapse
Affiliation(s)
- Masaya Takahashi
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan.
| | - Hiroko Iizuka
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Koyo Yoshida
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
| |
Collapse
|
6
|
Wilson-Morkeh H, Frise C, Youngstein T. Haemophagocytic lymphohistiocytosis in pregnancy. Obstet Med 2021; 15:79-90. [DOI: 10.1177/1753495x211011913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.
Collapse
Affiliation(s)
- Harold Wilson-Morkeh
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Charlotte Frise
- Fetal-Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- De Swiet’s Obstetric Medicine Centre, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
7
|
Ben Salem M, Bchir S, Taieb SK, Hamouda M, Mezrigui R, Ben Saleh M, Handous I, Letaief A, Aloui S, Skhiri H. Hemophagocytic Syndrome in a Pregnant Renal Transplant Recipient Associated With Cytomegalovirus Infection. EXP CLIN TRANSPLANT 2021; 19:739-743. [PMID: 34325626 DOI: 10.6002/ect.2021.0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hemophagocytic syndrome is a disorder of the mononuclear phagocytic system resulting in uncontrolled hemophagocytosis and cytokine overproduction. We report the first case of hemophagocytic syndrome, which occurred in a pregnantfemale patient 14 years after kidney transplant who displayed an atypical presentation and who had septic shock following cytomegalovirus infection. The patient, a-39-year-old woman at 27 weeks gestation with end-stage renal disease of unknown etiology, was admitted 14 years after living-donor kidney transplant (donor was her father) with high-grade fever, cough, and pancytopenia. Her immunosuppressant regimen included tacrolimus, azathioprine, and prednisone. Initially, she was hospitalized in the intensive care unit for septic shock without an identifiable focus of infection. She received intravenous broad-spectrum antibiotics before being transferred to our department following optimization of her hemodynamic status. Hemophagocytic syndrome was suspected, and bone marrow aspirate was performed, revealing macrophages with hemophagocytic activity. We confirmed the diagnosis of hemophagocytic syndrome given the presence of more than 5 criteria. We extensively investigated the underlying cause of hemophagocytic syndrome, and we diagnosed cytomegalovirus-induced hemophagocytic syndrome in a pregnant patient receiving immunosuppressive therapy after kidney transplantation. She was treated with corticosteroids and intravenous immunoglobulin. At 31 weeks gestation, she underwent a cesarean section; the baby developed newborn respiratory distress syndrome and died despite adequate resuscitation. We administered ganciclovir for 15 days following an increased cytomegalovirus viral load after delivery, leading to complete recovery.To date, optimal therapeutic and diagnostic guidelines for pregnancy-related hemophagocytic syndrome in female kidney transplant recipients are not well defined, and both patient and allograft survival rates remain low.
Collapse
Affiliation(s)
- Meriem Ben Salem
- From the Department of Nephrology, Dialysis and Kidney Transplantation, Fattouma Bourguiba University Hospital of Monastir, Tunisia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Liu L, Cui Y, Zhou Q, Zhao H, Li X. Hemophagocytic lymphohistiocytosis during pregnancy: a review of the literature in epidemiology, pathogenesis, diagnosis and treatment. Orphanet J Rare Dis 2021; 16:281. [PMID: 34154616 PMCID: PMC8215746 DOI: 10.1186/s13023-021-01790-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/25/2021] [Indexed: 12/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis during pregnancy is rare; it is often misdiagnosed, resulting in a high maternal and foetal mortality rate. Herein, based on limited case reports including antepartum and postpartum cases, we reviewed the current studies of pregnancy-related hemophagocytic lymphohistiocytosis, and compared the epidemiology, aetiology, diagnosis and treatment of pregnancy-related hemophagocytic lymphohistiocytosis with non-pregnancy, enriching the understanding of hemophagocytic lymphohistiocytosis and its treatment in obstetrics.
Collapse
Affiliation(s)
- Lidong Liu
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China
| | - Yutong Cui
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China
| | - Qiongjie Zhou
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Huanqiang Zhao
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China
| | - Xiaotian Li
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China. .,The Institute of Biomedical Science, Fudan University, Shanghai, China. .,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China.
| |
Collapse
|
9
|
Wang S, Wu J, Jing X, Zhang Y, Tang H, Wu J. Etoposide combined with ruxolitinib for refractory hemophagocytic lymphohistiocytosis during pregnancy: a case report and literature review. ACTA ACUST UNITED AC 2020; 24:751-756. [PMID: 33138732 DOI: 10.1080/16078454.2020.1838708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune-mediated disorder caused by uncontrolled inflammatory responses and the activation of T lymphocytes. This life-threatening disease, characterized by fever, cytopenia and hepatosplenomegaly, is extremely rare during pregnancy with high mortality. Despite the improvement of treatment regimen in recent years, HLH is still a great challenge for clinicians. Here, we described a 26-year-old woman who admitted to our hospital at her first pregnancy with pyrexia. Her condition continued to deteriorate after receiving broad-spectrum antimicrobials, presenting with fever, pancytopenia, hepatosplenomegaly, ferritin ≥ 500 μg/L, hemophagocytosis and low NK-cell activity. HLH was eventually diagnosed by clinical manifestation and laboratory examination results. Then the patient recovered well after treatment with etoposide combined with ruxolitinib therapy and underwent successful induced-labor operation. Additionally, we summarized similar cases from the literature to improve the management of HLH during pregnancy. In conclusion, this study highlights the challenges and difficulties in the diagnosis and management of patients with HLH during pregnancy. Moreover, this is the first case report of etoposide combined with ruxolitinib in the treatment of patients with refractory secondary HLH during pregnancy.
Collapse
Affiliation(s)
- Shuoshan Wang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Jingguo Wu
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Xiaoli Jing
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Yongwei Zhang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Hao Tang
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Junlin Wu
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| |
Collapse
|
10
|
Toscano M, Westen E, Hollenbach SJ, Perkins AS, Thornburg LL. A great pre-eclampsia masquerader. Hemophagocytic lymphohistiocytosis (HLH) presenting in pregnancy. CASE REPORTS IN PERINATAL MEDICINE 2020. [DOI: 10.1515/crpm-2019-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening disease. It is characterized by impaired natural killer cell and cytotoxic lymphocyte function leading to dysregulated macrophage phagocytosis of erythrocytes, leukocytes and platelets. Coupled with a massive release of cytokines this rapidly leads to multi-organ failure and mortality if not treated promptly.
Case presentation
We report a case of pregnancy-associated, treatment-resistant HLH with no identified risk factors.
Conclusion
It is likely that HLH is an unrecognized cause of intractable fever and disseminated intravascular coagulation (DIC) in young pregnant women and it should be included in the differential diagnosis when patients do not respond to typical therapies. High serum ferritin should further prompt consideration of this diagnosis. This rare disease is often not thought of and many gynecologist obstetricians have never heard of it, making this case report of essential importance to reignite the interest in HLH, particularly when it occurs during pregnancy.
Collapse
Affiliation(s)
- Marika Toscano
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , University of Rochester Medical Center , Rochester, NY , USA
| | - Elizabeth Westen
- Maternal Fetal Medicine Fellow, Instructor of Obstetrics and Gynecology , University of Rochester Medical Center , 601 Elmwood Ave, Box 668 , Rochester, NY 14624 , USA , Phone: +585.275.7480
| | - Stefanie J. Hollenbach
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , University of Rochester Medical Center , Rochester, NY , USA
| | - Archibald S. Perkins
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , University of Rochester Medical Center , Rochester, NY , USA
| | - Loralei L. Thornburg
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , University of Rochester Medical Center , Rochester, NY , USA
| |
Collapse
|
11
|
Yip KP, Ali M, Avann F, Ganguly S. Pregnancy-induced haemophagocytic lymphohistiocytosis. J Intensive Care Soc 2020; 21:87-91. [PMID: 32284723 PMCID: PMC7137163 DOI: 10.1177/1751143718809678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is an aggressive and life-threatening syndrome of excessive immune activation. It is associated with various aetiologies, including infections, collagen vascular diseases and malignancies. Pregnancy-induced immune dysregulation in genetically susceptible women may also play a critical role in haemophagocytic lymphohistiocytosis. Our case involves that of a 23-year-old pregnant woman who presented at 22 weeks gestation with tachycardia, swinging pyrexia, rigors and generalised myalgia. Refractory hypotension to intravenous fluids and rise in lactate level required admission to the intensive care unit for vasopressor support. Despite treatment with broad-spectrum antibiotics for presumed sepsis, she made little clinical improvement. Investigations for infection and rheumatological disease were unremarkable. A pronounced hyperferritinaemia, hypertriglyceridaemia and cytopenia raised the suspicion of haemophagocytic lymphohistiocytosis. Subsequent elevated CD25 levels helped establish the diagnosis. Treatment with corticosteroids and intravenous immunoglobulin provided a transient response in regard to temperature control and cardiovascular stability. The decision was made to treat her with anakinra, an interleukin-1 receptor antagonist. She responded well to this with a complete resolution of her symptoms and normalisation of her ferritin levels over the course of some weeks. Because of progressive slowing of foetal growth and abnormal umbilical artery Dopplers and cardiotocography, she eventually had an emergency caesarean section at 31 + 5 weeks. There were no foetal abnormalities.
Collapse
Affiliation(s)
- Kay Por Yip
- Intensive Care Unit, New Cross Hospital, Wolverhampton, UK
| | - Muzzammil Ali
- Intensive Care Unit, New Cross Hospital, Wolverhampton, UK
| | - Felicity Avann
- Intensive Care Unit, New Cross Hospital, Wolverhampton, UK
| | - Saibal Ganguly
- Intensive Care Unit, New Cross Hospital, Wolverhampton, UK
| |
Collapse
|
12
|
Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 772] [Impact Index Per Article: 154.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
Collapse
Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | |
Collapse
|
13
|
Zhang BB, Song Y, Wang Z. [Clinical diagnosis and treatment of perinatal stage hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:384-387. [PMID: 31207702 PMCID: PMC7342241 DOI: 10.3760/cma.j.issn.0253-2727.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To analyze the clinical features of patients with hemophagocytic lymphohistiocytosis (HLH) during perinatal stage. Methods: From January 2011 to October 2016, the obstetric materials, clinical features, associated disease/factors and therapeutic outcomes were studied in 11 patients with HLH in perinatal period. Results: In these 11 patients, 9 were primipara. As for the onset time of HLH, 5 were before delivery and 6 were after delivery. Six were complicated with other associated disease/factors, and infection was the commonest (5/6) . Treatment included glucocorticoid + fludarabine in 1 case, HLH-94/04 protocols in 9 cases, and monotherapy corticosteroids in 1 case. Two patients died eventually. Conclusions: Perinatal HLH is commonly observed in the pregnancy/postpartum related HLH (28th week of pregnancy to one week after delivery) . Infection is still the commonest associated factors. HLH-94/04 protocols after the cessation of pregnancy may be effective, but the cessation of pregnancy itself may not be enough for the perinatal stage related-HLH. The perinatal stage related-HLH still has a better outcome than the other subtype of secondary-HLH.
Collapse
Affiliation(s)
- B B Zhang
- Department of Hematology, People's Hospital of Yinzhou, Ningbo 315100, China
| | - Y Song
- Department of Hema-tology, Beijing Friendship Hospital, Beijing 100050, China
| | - Z Wang
- Department of Hema-tology, Beijing Friendship Hospital, Beijing 100050, China
| |
Collapse
|
14
|
Cheng J, Niu J, Wang Y, Wang C, Zhou Q, Chen Y, Zhang Y, Lin J, Di W. Hemophagocytic lymphohistiocytosis in pregnancy: a case report and review of the literature. J OBSTET GYNAECOL 2019; 40:153-159. [PMID: 31215279 DOI: 10.1080/01443615.2019.1601168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jie Cheng
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaxin Niu
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chuan Wang
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiong Zhou
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunyan Chen
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Zhang
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jianhua Lin
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Di
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
15
|
Song Y, Wang Z, Hao Z, Li L, Lu J, Kang H, Lu Y, You Y, Li L, Chen Q, Chen B. Requirement for etoposide in the treatment of pregnancy related hemophagocytic lymphohistiocytosis: a multicenter retrospective study. Orphanet J Rare Dis 2019; 14:50. [PMID: 30777105 PMCID: PMC6380007 DOI: 10.1186/s13023-019-1033-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 11/20/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare severe clinical syndrome. HLH manifesting during pregnancy has been paid much attention in recent years. Despite the specificity of pregnancy-related HLH, there has not been any consensus regarding its treatment. According to a previous study, corticosteroid/IVIG is the mainstream therapy; however, the efficacy is controversial. Etoposide is an important agent in the HLH-94 regimen; nevertheless, its use is limited because of possible toxicity to the fetus. Methods: In this study, we summarized 13 cases from 4 medical institutions from April 2011 to April 2018. Treatment regimens and outcomes were observed. Results The median age was 26 (20–36) years old. The median gestational age was 28 (10–35) weeks. In these 13 patients, 10 were treated with methylprednisolone/IVIG and was effective in only two patients. In 6 patients who used etoposide during their treatment, all achieved remission. The median time from onset of disease to use of etoposide was 36 (17–131) days. Five of these 6 patients were treated with corticosteroids with/without IVIG before etoposide. One patient with pulmonary tuberculosis and one with lymphoma were treated according to etiology and achieved long survival. Conclusion For treatment of pregnancy-related HLH, particularly for patients who do not respond to corticosteroids/IVIG therapy, etoposide should be used bravely. Nevertheless, suitable dosages and toxic and side-effects require further clinical observation.
Collapse
Affiliation(s)
- Yue Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China.
| | - Zengping Hao
- Department of Obstetrics and Gynecology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lihong Li
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Junli Lu
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hongjun Kang
- Department of Hematology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yanping Lu
- Department of Obstetrics and Gynecology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yanqin You
- Department of Obstetrics and Gynecology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Lijuan Li
- Department of Intensive Care Unit, China-Japan Friendship Hospital, Beijing, China
| | - Qingyun Chen
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Bo Chen
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
16
|
Parrott J, Shilling A, Male HJ, Holland M, Clark-Ganheart CA. Hemophagocytic Lymphohistiocytosis in Pregnancy: A Case Series and Review of the Current Literature. Case Rep Obstet Gynecol 2019; 2019:9695367. [PMID: 30891322 PMCID: PMC6390238 DOI: 10.1155/2019/9695367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/29/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that can be fatal in pregnancy. We report two cases of severe HLH that highlight etoposide use in pregnancy. CASE 1 28-year-old G2P1 with lupus presented at 18 weeks with acute hypoxic respiratory failure, hepatic dysfunction, leukopenia, thrombocytopenia, and elevated ferritin. Bone marrow biopsy confirmed HLH. Etoposide and corticosteroid treatment was initiated per HLH protocol; however clinical status declined rapidly. Fetal demise occurred at 21 weeks and she subsequently suffered a massive cerebral vascular accident. She was transitioned to comfort measures and the patient deceased. CASE 2 37-year-old G4P3 presented at 25 weeks with fever, acute liver failure, thrombocytopenia, and elevated ferritin. HLH treatment was initiated, including etoposide, and diagnosis confirmed with liver biopsy. Fetal growth restriction was diagnosed at 27 weeks. Delivery occurred at 37 weeks. The neonate was found to be CMV positive despite negative maternal serology. CONCLUSION The addition of etoposide to corticosteroid use is a key component in HLH treatment of nonpregnant individuals. While this is usually avoided in pregnancy, the benefit to the mother may outweigh the potential harm to the fetus in severe cases and it should be strongly considered.
Collapse
Affiliation(s)
- Jessica Parrott
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Alexander Shilling
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Heather J. Male
- Division of Hematologic Malignancies and Cellular Therapeutics, Department of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Marium Holland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Cecily A. Clark-Ganheart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| |
Collapse
|
17
|
Song Y, Wang JS, Wang YN, Wang Z. Hemophagocytic Lymphohistiocytosis during the Postpartum Stage of Pregnancy: A Report of Eight Cases. Acta Haematol 2018; 141:55-60. [PMID: 30537757 DOI: 10.1159/000493879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 09/18/2018] [Indexed: 12/16/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare and severe clinical syndrome that can be classified as either primary or secondary. Secondary HLH can be triggered by a variety of diseases. Pregnancy-related HLH has already been observed clinically. However, most of these cases occur during pregnancy. Considering that the periods before and after delivery have different clinical features, we presented the first case series of HLH that presented during the postpartum stage of pregnancy. From these cases, we concluded that postpartum HLH is a common form of pregnancy-related HLH. Patients with postpartum HLH may suffer more complicated pathogenesis. Cytopenia was not as common as in other types of HLH, but liver dysfunction was present in almost all cases. The standard therapy of HLH-94/04 was very effective, and the outcomes of postpartum HLH were better.
Collapse
Affiliation(s)
- Yue Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing-Shi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi-Ni Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China,
| |
Collapse
|
18
|
Sarkissian S, Khan Y, Farrell D, Constable D, Brem E. Hemophagocytic lymphohistiocytosis in the setting of HELLP Syndrome. Clin Case Rep 2018; 6:2466-2470. [PMID: 30564350 PMCID: PMC6293182 DOI: 10.1002/ccr3.1828] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/12/2018] [Accepted: 08/19/2018] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper activation of the immune system. Rare cases associated with HELLP syndrome and other similar conditions in pregnancy have been reported. Despite the improved survival rates with etoposide and dexamethasone-based regimens, HLH remains a challenging disease. Experience in pregnant patients is exceedingly rare.
Collapse
Affiliation(s)
| | - Yasir Khan
- Division of Hematology and Oncology, Department of MedicineUniversity of California, IrvineIrvineCalifornia
| | - Daniel Farrell
- Department of PathologyUniversity of California, IrvineIrvineCalifornia
| | - David Constable
- Division of Infectious Disease, Department of MedicineUniversity of California, IrvineIrvineCalifornia
| | - Elizabeth Brem
- Division of Hematology and Oncology, Department of MedicineUniversity of California, IrvineIrvineCalifornia
| |
Collapse
|
19
|
Neistadt B, Carrubba A, Zaretsky MV. Natural killer/T-cell lymphoma and secondary haemophagocytic lymphohistiocytosis in pregnancy. BMJ Case Rep 2018; 2018:bcr-2018-224832. [PMID: 30219776 DOI: 10.1136/bcr-2018-224832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal disorder. It is challenging to diagnose due to its rarity and variation in clinical presentation, laboratory abnormalities and underlying aetiologies. A reproductive-aged woman, gravida 2 para 1001 at 27 weeks gestation presented with fever, hypotension and subacute upper respiratory infection. She delivered a male infant by caesarean section secondary to fetal distress. Subsequently, she was diagnosed with T-cell lymphoma and secondary HLH. Despite management with supportive care and multiple chemotherapeutic agents, she ultimately died of multiorgan failure. Patients with HLH secondary to malignancy have a particularly poor prognosis. This case highlights the importance of considering secondary HLH in the differential diagnosis of a patient with fever, pancytopenia and systemic symptoms of unclear aetiology in pregnancy.
Collapse
Affiliation(s)
- Barbara Neistadt
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aakriti Carrubba
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, Colorado, USA
| |
Collapse
|
20
|
Yildiz H, Vandercam B, Thissen X, Komuta M, Lanthier N, Debieve F, Dahlqvist G. Hepatitis during pregnancy: A case of hemophagocytic lymphohistiocytosis. Clin Res Hepatol Gastroenterol 2018; 42:e49-e55. [PMID: 29239849 DOI: 10.1016/j.clinre.2017.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/24/2017] [Indexed: 02/04/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but severe and potentially fatal syndrome that can occur during pregnancy. A 36 years-old woman, at 29 weeks of gestation, presented with itchiness and jaundice since a week. On clinical examination she was apyrexial and frankly icteric. Laboratory data showed evidence of acute hepatitis. A complete work-up was made excluding viral hepatitis (HAV, HEV, HBV, HCV, HHV6, CMV, EBV) and autoimmune liver disease. Liver diseases related to pregnancy were not completely excluded. A liver biopsy was performed and firstly interpreted as showing features of acute hepatitis. The clinical situation worsened, she developed fever with signs of fetal distress and emergent delivery was done. A second look at the liver biopsy showed features compatible with HLH, which was also confirmed on bone marrow biopsy. Extensive work-up with exclusion of infectious and malignant diseases, lead us to the diagnosis of HLH secondary to pregnancy and short term steroid therapy was started. She then completely recovered and didn't present any relapse after 4 months of follow up. HLH during pregnancy is very rare and this is the first case of HLH presenting as acute hepatitis and diagnosed on a liver biopsy.
Collapse
Affiliation(s)
- Halil Yildiz
- Department of internal medicine and infectiology, cliniques universitaires St Luc, 10, avenue hippocrate, 1200 Brussels, Belgium.
| | - Bernard Vandercam
- Department of internal medicine and infectiology, cliniques universitaires St Luc, 10, avenue hippocrate, 1200 Brussels, Belgium
| | - Xave Thissen
- Department of internal medicine and infectiology, cliniques universitaires St Luc, 10, avenue hippocrate, 1200 Brussels, Belgium
| | - Mina Komuta
- Department of pathology, cliniques universitaires St Luc, 1200 Brussels, Belgium
| | - Nicolas Lanthier
- Department of gastroenterology, cliniques universitaires St Luc, 1200 Brussels, Belgium
| | - Frederic Debieve
- Department of gynecology and obstetric, cliniques universitaires St Luc, 1200 Brussels, Belgium
| | - Geraldine Dahlqvist
- Department of gastroenterology, cliniques universitaires St Luc, 1200 Brussels, Belgium
| |
Collapse
|
21
|
He M, Jia J, Zhang J, Beejadhursing R, Mwamaka Sharifu L, Yu J, Wang S, Feng L. Pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma: A case report and literature review. Medicine (Baltimore) 2017; 96:e8628. [PMID: 29381934 PMCID: PMC5708933 DOI: 10.1097/md.0000000000008628] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) occurs primarily in pediatric population, or secondary to malignancy, infection, or autoimmune disease. This disease is rare and prognosis is generally poor. Only a small number of cases during pregnancy have been reported in literature. PATIENT CONCERNS We report a case of pregnancy-associated HLH secondary to natural killer (NK)/T cells lymphoma. She was admitted at 30 weeks and 3 days of pregnancy with complaints of abdominal pain and fever as high as 39.2°C. The patient was found to have splenomegaly, pancytopenia, and acute hepatic failure. DIAGNOSES A subsequent bone marrow biopsy revealed focal hemophagocytosis and atypical lymphoid cells. The splenic pulp also contained a large number of tissue cells proliferating and devouring mature red blood cells, lymphocytes, and cell debris. On the basis of these findings, we diagnosed the case as pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma. INTERVENTIONS Treatment consisted with dexamethasone and etoposide in combination with rituximab. OUTCOMES Due to timely termination of pregnancy, the neonate was in good condition. However, the patient died on the 18th day postoperation due to multiorgan failure. LESSONS We recommend that HLH be considered as differential diagnosis in a pregnant patient complaining of persistent fever, cytopenia, or declining clinical condition despite delivery of the baby. Prompt diagnosis and treatment is essential and fetal outcomes should also be considered. The decision to terminate a pregnancy and initiate chemotherapy during pregnancy with malignancy-associated HLH (M-HLH) needs to be further investigated in a larger cohort.
Collapse
|
22
|
Rousselin A, Alavi Z, Le Moigne E, Renard S, Tremouilhac C, Delluc A, Merviel P. Hemophagocytic syndrome in pregnancy: case report, diagnosis, treatment, and prognosis. Clin Case Rep 2017; 5:1756-1764. [PMID: 29152265 PMCID: PMC5676265 DOI: 10.1002/ccr3.1172] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/28/2017] [Accepted: 08/07/2017] [Indexed: 01/24/2023] Open
Abstract
Diagnosis of hemophagocytic syndrome remains a challenge in particular during pregnancy. Concomitant presence of clinical and biological signs, for example, fever, pancytopenia, hyperferritinemia, and hypertriglyceridemia, should alert clinicians to suspect HPS and proceed to prompt treatments.
Collapse
Affiliation(s)
- Aline Rousselin
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| | - Zarrin Alavi
- Inserm CIC 1412 Brest Medical University Hospital Brest France
| | | | - Sarah Renard
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| | | | - Aurélien Delluc
- Department of Internal Medicine Brest Medical University Hospital Brest France
| | - Philippe Merviel
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| |
Collapse
|
23
|
Kerley RN, Kelly RM, Cahill MR, Kenny LC. Haemophagocytic lymphohistiocytosis presenting as HELLP syndrome: a diagnostic and therapeutic challenge. BMJ Case Rep 2017; 2017:bcr-2017-219516. [PMID: 28433984 DOI: 10.1136/bcr-2017-219516] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal, haematological disorder, which can be clinically challenging to diagnose and manage. We report a case of HLH in a previously healthy 33-year-old primigravida. The patient presented at 22 weeks gestation with dyspnoea, abdominal pain, anaemia, thrombocytopenia and elevated liver enzymes suggestive of HELLP syndrome.HELLP, a syndrome characterised by haemolysis, elevated liver enzymes and low platelets is considered a severe form of pre-eclampsia. Despite delivery of the fetus, her condition deteriorated over 3-4 days with high-grade fever, worsening thrombocytopenia and anaemia requiring transfusion support. A bone marrow biopsy showed haemophagocytosis and a diagnosis of HLH was made. Partial remission was achieved with etoposide-based chemotherapy and complete remission following bone marrow transplantation. Eleven months post-transplant, the disease aggressively recurred, and the patient died within 3 weeks of relapse.
Collapse
Affiliation(s)
| | | | - Mary Rose Cahill
- Cork University Hospital, University College Cork, Cork City, Ireland
| | - Louise Clare Kenny
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, University College Cork, Cork, Ireland
| |
Collapse
|
24
|
Liu AC, Yang Y, Li MT, Jia Y, Chen S, Ye S, Zeng XZ, Wang Z, Zhao JX, Liu XY, Zhu J, Zhao Y, Zeng XF, Li ZG. Macrophage activation syndrome in systemic lupus erythematosus: a multicenter, case-control study in China. Clin Rheumatol 2017; 37:93-100. [PMID: 28409239 DOI: 10.1007/s10067-017-3625-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 01/10/2023]
Abstract
The objective of this study was to describe the clinical and laboratory characteristics, precipitating factors, treatment, and outcome of macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE). A multicenter case-control study was performed across six tertiary hospitals from 1997 to 2014. A total of 32 patients with SLE-associated MAS were enrolled. Sixty-four age- and sex-matched SLE patients diagnosed in the same period without MAS episodes were selected as controls. The most frequent clinical feature was fever, followed by splenomegaly. Hyperferritinemia, hypoalbuminemia, and hyper-lactate dehydrogenase (LDH)-nemia were among the most common laboratory abnormalities. Compared with pre-MAS visit, patients at the onset of MAS had greater frequencies of renal involvement, liver dysfunction, and cytopenia. Receiver operating characteristic (ROC) analysis identified optimal cutoff values of ferritin (>662.5 ng/mL) and LDH (>359 U/mL) to predict the occurrence of MAS in SLE. SLE flare and infection were the common triggers of MAS in SLE. Abortion and parturition were recorded as well. The overall mortality rate was 12.5%. All patients received corticosteroids. Cyclosporine A, cyclophosphamide, and etoposide were the three most commonly used immunosuppressants. Rituximab was given to one patient. Intravenous immunoglobulin (IVIG) was added for 46.9% patients. MAS is a potentially fatal complication of SLE. Its occurrence is most frequently associated with active SLE disease or infection. The presentation of unexplained fever, cytopenia, or liver dysfunction, with high levels of ferritin and LDH, in patients with SLE should raise the suspicion of MAS. Corticosteroids with immunosuppressants and IVIG may be an appropriate treatment.
Collapse
Affiliation(s)
- Ai-Chun Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China
| | - Yue Yang
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuan Jia
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China.
| | - Sheng Chen
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Xiang-Zong Zeng
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Zhao Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Jin-Xia Zhao
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Xiang-Yuan Liu
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Jian Zhu
- Department of Rheumatology, General Hospital of the People's Liberation Army, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Feng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhan-Guo Li
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China
| |
Collapse
|
25
|
Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
26
|
Takada H, Kimura N, Yoshihashi-Nakazato Y, Kawahata K, Kohsaka H. Discoid Lupus Erythematosus Complicated with Pregnancy-induced Hemophagocytic Syndrome. Intern Med 2017. [PMID: 28626188 PMCID: PMC5505918 DOI: 10.2169/internalmedicine.56.8156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 35-year-old woman with discoid lupus erythematosus (DLE) was admitted at 11 weeks' gestation with a persistent fever. Laboratory studies revealed pancytopenia, elevated liver enzymes, and hyperferritinemia. Bone marrow aspiration confirmed the diagnosis of hemophagocytic syndrome (HPS). She had no findings of infection or active systemic lupus erythematosus. The administration of high-dose corticosteroids resolved the clinical and laboratory findings. She delivered a healthy baby at 35 weeks' gestation. This case suggests that DLE can be a predisposing factor for pregnancy-induced HPS.
Collapse
Affiliation(s)
- Hideto Takada
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Naoki Kimura
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Yoko Yoshihashi-Nakazato
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Kimito Kawahata
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| |
Collapse
|
27
|
Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|