1
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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.
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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
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2
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Sun L, Li P, Pang B, Wu P, Wang R. Gestational Psittacosis With Secondary Hemophagocytic Syndrome: A Case Report and Literature Review. Front Med (Lausanne) 2021; 8:755669. [PMID: 34869453 PMCID: PMC8636855 DOI: 10.3389/fmed.2021.755669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022] Open
Abstract
Gestational psittacosis and hemophagocytic syndrome (HPS) are rare clinical diseases. In this article, a case of gestational psittacosis concomitant with secondary HPS was reported. An analysis was performed on the clinical characteristics, signs, laboratory findings, progression, diagnosis, and treatment of a patient with gestational psittacosis concomitant with secondary HPS. Besides, the literature with respect to this disease was reviewed. This patient was definitively diagnosed through metagenomic next-generation sequencing techniques, bone marrow puncture and smear examination, and the determination of sCD25 level and natural killer (NK) cell activity. Anti-infectives such as doxycycline and etoposide combined with hormone chemotherapy achieved significant improvement in cough and expectoration, a return to normal temperature, and a significant improvement in oxygenation index. In addition, chest computed tomography revealed obvious absorption of lung lesions and a return of NK cell activity and sCD25 levels to normal ranges. Chlamydia psittaci pneumonia requires a clear determination of etiology, while HPS requires bone marrow puncture and smear examination, together with the determination of sCD25 level and NK cell activity in the blood. The findings of this study suggest that metagenomic next-generation sequencing is an effective instrument in clearly identifying pathogens that cause lung infection. Clinicians should consider atypical pathogens of lung infection in patients with poor response to empirical anti-infectives, and strive to design an effective treatment strategy as per an accurate diagnosis based on the etiology. As for patients suffering from long-term high fever and poor temperature control after broad-spectrum antibiotic treatment, non-infectious fever should be taken into account. A rapid and clear diagnosis would significantly improve patient prognosis.
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Affiliation(s)
- Li Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Pulin Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Bo Pang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Peipei Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ran Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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3
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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.
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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
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4
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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: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 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.
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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.
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5
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Ahn SS, Lee B, Kim D, Jung SM, Lee SW, Park MC, Park YB, Hwang YG, Song JJ. Evaluation of macrophage activation syndrome in hospitalised patients with Kikuchi-Fujimoto disease based on the 2016 EULAR/ACR/PRINTO classification criteria. PLoS One 2019; 14:e0219970. [PMID: 31318961 PMCID: PMC6638985 DOI: 10.1371/journal.pone.0219970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/06/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To evaluate the impact of macrophage activation syndrome (MAS) on clinical features in patients with Kikuchi-Fujimoto disease (KFD) and to compare the features of MAS in KFD with those of adult-onset Still's disease (AOSD) and systemic lupus erythematosus (SLE). METHODS The medical records of febrile patients hospitalised with KFD between November 2005 and April 2017 were reviewed. Patients fulfilling the 2016 classification criteria for MAS were classified as having MAS. Clinical and laboratory features of patients with KFD with and without MAS were evaluated. Poor hospitalisation outcomes were defined as intensive care unit admission or in-hospital mortality. The treatment outcomes of MAS in KFD, AOSD, and SLE were also compared. RESULTS Among 78 patients hospitalised with KFD, 24 (30.8%) patients had MAS during admission. Patients with KFD and MAS more frequently required glucocorticoid treatment (66.7% vs 40.7%, p = 0.036) and had longer hospital stays than patients with KFD without MAS (12.5 vs 8.5 days, p<0.001). In addition, patients with MAS had worse hospitalisation outcomes than patients without MAS (29.2% vs. 0.0%, p<0.001). Among patients with MAS in KFD, AOSD, and SLE, the number of patients requiring glucocorticoid treatment after 3 months was significantly lower among patients with MAS and KFD (KFD 33.3%, AOSD 88.9%, SLE 100%, p<0.001). CONCLUSIONS The presence of MAS in KFD was associated with adverse clinical outcomes including higher steroid usage and worse hospitalisation outcomes. However, compared to those with AOSD and SLE, patients with MAS and KFD were less likely to require long-term glucocorticoid treatment.
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Affiliation(s)
- Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeori Lee
- Department of Internal Medicine, Albert Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Dam Kim
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Gil Hwang
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
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6
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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
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7
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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.
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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
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8
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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.
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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
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9
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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.
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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
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10
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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.
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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
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11
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Nasser MF, Sharma S, Albers E, Sharma S, Duggal A. Pregnancy-related Hemophagocytic Lymphohistiocytosis Associated with Herpes Simplex Virus-2 Infection: A Diagnostic Dilemma. Cureus 2018; 10:e2352. [PMID: 29796364 PMCID: PMC5959312 DOI: 10.7759/cureus.2352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe inflammatory disorder characterized by the uncontrolled proliferation of lymphocytes and histiocytes with hemophagocytic activity in the bone marrow. To our knowledge, there have been a few reported cases of pregnancy-related HLH. This case highlights the importance of considering HLH in a pregnant woman along with other diagnoses, such as HELLP (which stands for hemolysis, elevated liver enzyme levels, and low platelet levels) syndrome and hemolytic anemias. It points to the challenges of diagnosing and managing pregnancy-related HLH due to a similarity in presentation with other conditions.
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Affiliation(s)
| | | | | | - Sapna Sharma
- Internal Medicine, Mahatma Gandhi Mission Institute of Health Sciences
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12
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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.
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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
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13
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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.
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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
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14
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Acute Liver Failure Secondary to Hemophagocytic Lymphohistiocytosis during Pregnancy. ACG Case Rep J 2016; 3:e162. [PMID: 27921061 PMCID: PMC5126497 DOI: 10.14309/crj.2016.135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/25/2016] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune activation that mimics and occurs with other systemic diseases. A 35-year-old female presented with signs of viral illness at 13 weeks of pregnancy and progressed to acute liver failure (ALF). We discuss the diagnosis of HLH and Kikuchi-Fujimoto (KF) lymphadenitis in the context of pregnancy and ALF. HLH may respond to comorbid disease-specific therapy, and more toxic treatment can be avoided.
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15
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Tumian NR, Wong CL. Pregnancy-related hemophagocytic lymphohistiocytosis associated with cytomegalovirus infection: A diagnostic and therapeutic challenge. Taiwan J Obstet Gynecol 2016; 54:432-7. [PMID: 26384065 DOI: 10.1016/j.tjog.2014.11.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2014] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis (HLH) is a disorder characterized by uncontrolled mature histiocyte proliferation, hemophagocytosis, and hypercytokinemia. We describe a previously healthy pregnant patient who presented in the third trimester of pregnancy with HLH. CASE REPORT A 35-year-old woman presented at 38 weeks' gestation with pyrexia, jaundice, severe anemia, elevated liver enzymes, and lactate dehydrogenase suggestive of HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. Unfortunately, her condition deteriorated and she was ventilated in the intensive care unit despite delivery of the baby and administration of dexamethasone. She developed microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment suggestive of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome. However, she was refractory to plasma exchange, intravenous immunoglobulin, and broad-spectrum antibiotics. HLH was eventually diagnosed from biochemical and bone marrow findings. An extensive search for possible causes yielded negative results. She improved significantly with intravenous dexamethasone and cyclosporine A and was transferred out of the intensive care unit. Unfortunately, she developed cytomegalovirus disease 2 weeks later, which improved transiently with intravenous ganciclovir; later, however, she succumbed to multidrug-resistant nosocomial infections, rapidly progressive cytomegalovirus disease, and multiorgan failure. CONCLUSION This case highlights the challenges and difficulties involved in the diagnosis and management of pregnancy-related HLH. Immunosuppressive treatment for HLH can precipitate life-threatening opportunistic infections, which need to be promptly diagnosed and treated.
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Affiliation(s)
- Nor Rafeah Tumian
- Hematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia
| | - Chieh Lee Wong
- Hematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia.
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16
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Samra B, Yasmin M, Arnaout S, Azzi J. Idiopathic Hemophagocytic Lymphohistiocytosis During Pregnancy Treated with Steroids. Hematol Rep 2015; 7:6100. [PMID: 26487936 PMCID: PMC4591502 DOI: 10.4081/hr.2015.6100] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe clinical syndrome characterized by a dysregulated hyperinflammatory immune response. The diagnosis of HLH during pregnancy is especially challenging due to the rarity of this condition. The highly variable clinical presentation, laboratory findings, and associated diagnoses accompanying this syndrome further complicate the problem. A pronounced hyperferritinemia in the setting of systemic signs and symptoms along with a negative infectious and rheumatological workup should raise suspicions for HLH. While treatment ideally consists of immunosuppressive chemotherapy and hematopoietic stem cell transplant, the potential toxicity to both the pregnant woman and the fetus poses a challenging decision. We report the first case of idiopathic HLH presenting as fever of unknown origin in a pregnant woman successfully treated with steroids.
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Affiliation(s)
- Bachar Samra
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
| | - Mohamad Yasmin
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
| | - Sami Arnaout
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
| | - Jacques Azzi
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
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17
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Pregnancy induced haemophagocytic syndrome. J Obstet Gynaecol India 2012; 63:203-5. [PMID: 24431639 DOI: 10.1007/s13224-011-0073-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 08/29/2011] [Indexed: 10/28/2022] Open
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18
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Hannebicque-Montaigne K, Le Roc’h A, Launay D, Coulon C, Deruelle P, Langlois S. Syndrome d’activation macrophagique et grossesse : à propos d’un cas. ACTA ACUST UNITED AC 2012; 31:239-42. [DOI: 10.1016/j.annfar.2011.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 11/25/2011] [Indexed: 11/26/2022]
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19
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Kim JM, Kwok SK, Ju JH, Kim HY, Park SH. Reactive hemophagocytic syndrome in adult Korean patients with systemic lupus erythematosus: a case-control study and literature review. J Rheumatol 2011; 39:86-93. [PMID: 22174206 DOI: 10.3899/jrheum.110639] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To determine the characteristics of hemophagocytic syndrome (HPS) in adult Korean patients with systemic lupus erythematosus (SLE). METHODS We reviewed the medical records of 1033 adult patients with SLE for a recent 14-year period and identified 15 patients who had developed HPS. Forty-two age- and sex-matched patients with SLE admitted for other manifestations were included as disease controls. Features of HPS in these patients were analyzed. RESULTS Reactive HPS occurred from some distinct causes during the course of SLE. HPS was associated with SLE in 11 patients (4 at onset of SLE and 7 at SLE flare), infection in 3 patients (2 bacterial infection; 1 viral infection), and drug use (azathioprine) in 1 patient. Common clinical features included fever (93.3%), hepatomegaly (60.0%), and splenomegaly (60.0%). Steroid pulse therapy (46.7%), immunosuppressants (46.7%), and intravenous immunoglobulin (46.7%) were frequently used for treatment of HPS. One patient (6.7%) died. Compared with SLE patients without HPS, those with HPS showed a higher SLEDAI score (p = 0.003) and lower levels of plasma leukocytes (p < 0.001), hemoglobin (p = 0.013), and platelets (p < 0.001) as well as a higher serum C-reactive protein level (p = 0.039) and a lower serum albumin level (p = 0.004). CONCLUSION HPS was observed in 1.5% of adult Korean patients with SLE. The occurrence of HPS was most frequently associated with the SLE disease activity. Profound pancytopenia, a high SLEDAI score, and notable changes in the level of acute-phase reactants can be the characteristics of SLE patients with HPS.
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Affiliation(s)
- Ji-Min Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 505, Banpo-dong, Seocho-gu, Seoul, 137-040, Republic of Korea
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20
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Lee HY, Huang YC, Lin TY, Huang JL, Yang CP, Hsueh T, Wu CT, Hsia SH. Primary Epstein-Barr virus infection associated with Kikuchi's disease and hemophagocytic lymphohistiocytosis: a case report and review of the literature. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 43:253-7. [PMID: 21291855 DOI: 10.1016/s1684-1182(10)60040-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/30/2009] [Accepted: 06/19/2009] [Indexed: 11/29/2022]
Abstract
An association between hemophagocytic lymphohistiocytosis (HLH) and Kikuchi's disease is rarely seen in children. Here, we present the case of a male adolescent (age 16 years and 3 months) who suffered from spiking fever for more than 1 week, and multiple nodules over the neck and bilateral axilla for 2 months. A skin rash also developed over all four limbs, abdomen and face. Laboratory data and skin biopsy gave results compatible with a diagnosis of Kikuchi's disease. Hemophagocytosis in the bone marrow, hyper-triglyceridemia, elevated ferritin, and splenomegaly were also found, fulfilling the criteria for HLH. A recent primary Epstein-Barr virus infection was also diagnosed by serology. The patient ran a relatively benign course. Intravenous immunoglobulins, steroids or etoposide-containing regimens were not used, and his recovery was uneventful. A review of the literature showed that up to February 2009, 11 additional cases of Kikuchi's disease presenting simultaneously with, or mimicking, HLH had been reported. Complete resolution within several weeks, with no recurrence, was seen in all but one patient (a pregnant woman).
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Affiliation(s)
- Hao-Yuan Lee
- Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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21
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Macrophage activation syndrome resistant to medical therapy in a patient with systemic lupus erythematosus and its remission with splenectomy. Rheumatol Int 2010; 33:767-71. [DOI: 10.1007/s00296-010-1654-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 11/14/2010] [Indexed: 10/18/2022]
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22
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Astudillo L. [Kikuchi-Fujimoto disease]. Rev Med Interne 2010; 31:757-65. [PMID: 20605287 DOI: 10.1016/j.revmed.2010.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 11/07/2009] [Accepted: 01/01/2010] [Indexed: 01/30/2023]
Abstract
Kikuchi-Fujimoto disease is a necrotizing lymphadenitis, involving young patients, predominantly females. Lymphadenopathy is usually localized, particularly in the cervical area, mostly unilateral and tender. Fever is present in one third of cases. Associated skin lesions, arthralgia, myalgia, splenomegaly or hepatomegaly are rare. Laboratory evaluation shows a slight increase of erythrocyte sedimentation rate and leukopenia. Kikuchi-Fujimoto has been reported in association with other diseases, including systemic lupus, Still's disease, hemophagocytosis, pregnancy, other autoimmune diseases, and cancer. A viral or bacterial origin has been suspected but not confirmed. Lymph node biopsy allows the diagnosis and shows necrotizing lymphadenitis with acidophil necrosis, CD68+ histiocyte infiltrate, presence of plasmacytoid monocytes, multiple apoptotic cells (CD8+ T cell) with nuclear dust, immunoblastic reaction and the absence of neutrophils or eosinophils. The disease course is usually spontaneously favourable in few weeks or months, requiring corticosteroids only occasionally.
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Affiliation(s)
- L Astudillo
- Service de médecine interne, CHU Purpan, Toulouse cedex, France.
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23
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Chien CT, Lee FJ, Luk HN, Wu CC. Anesthetic management for cesarean delivery in a parturient with exacerbated hemophagocytic syndrome. Int J Obstet Anesth 2009; 18:413-6. [PMID: 19700307 DOI: 10.1016/j.ijoa.2009.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Revised: 12/15/2008] [Accepted: 02/28/2009] [Indexed: 12/31/2022]
Abstract
Hemophagocytic syndrome is an uncommon disease characterized by cytokine dysfunction and uncontrolled hemophagocytosis. It arises rarely during pregnancy, in which case maternal and fetal mortality are relatively high. It has some similarities with HELLP syndrome. Poor maternal condition increases the risk of preterm labor and the possibility of emergency cesarean delivery in non-optimal conditions, presenting a great challenge to the anesthesiologists. We report a 28-year-old primigravida with the onset of hemophagocytic syndrome and cyopenia at 23 weeks of gestation. A further exacerbation at 28 weeks of gestation brought on preterm labor. General anesthesia was provided successfully for cesarean delivery. The patient recovered completely after this episode. We suggest that early diagnosis, multi-disciplinary intervention, pre-operative correction of the hematological abnormalities, general anesthesia and close postoperative monitoring are necessary.
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Affiliation(s)
- C-T Chien
- Department of Anesthesiology, Taichung Verterans General Hospital, No.160, Sec. 3, Chung-Kang Road Rd., Taichung City 40705, Taiwan.
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24
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Lin YW, Horiuchi H, Ueda I, Nambu M. Recurrent hemophagocytic lymphohistiocytosis accompanied by Kikuchi's disease. Leuk Lymphoma 2009; 48:2447-51. [DOI: 10.1080/10428190701644322] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Teng CL, Hwang GY, Lee BJ, Wang RC, Chou MM. Pregnancy-induced hemophagocytic lymphohistiocytosis combined with autoimmune hemolytic anemia. J Chin Med Assoc 2009; 72:156-9. [PMID: 19299225 DOI: 10.1016/s1726-4901(09)70043-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), presenting with fever, cytopenia, liver dysfunction, hepatosplenomegaly, hypertriglyceridemia, and hyperferritinemia, is associated with various etiologies, including infections, collagen vascular diseases, and malignancies. The present report describes a 28-year-old woman who developed HLH combined with autoimmune hemolytic anemia (AIHA) at 23 weeks of gestation. Without response to corticosteroid, the patient completely recovered from both HLH and AIHA after termination of the pregnancy. Pregnancy-induced immune dysregulation and cytokine overproduction in genetically susceptible women may play critical roles in HLH. The differential diagnosis of pregnant women with fever and cytopenia should include HLH. Pregnancy termination should be considered when pregnancy-induced HLH is refractory to medical treatment.
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Affiliation(s)
- Chieh-Lin Teng
- Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.
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26
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Viallard JF, Parrens M, Lazaro E, Caubet O, Pellegrin JL. Lymphadénite histiocytaire nécrosante ou maladie de Kikuchi-Fujimoto. Presse Med 2007; 36:1683-93. [PMID: 17611068 DOI: 10.1016/j.lpm.2007.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Kikuchi-Fujimoto disease (KFD), first described independently by Kikuchi and Fujimoto in 1972, is a subacute necrotizing lymphadenitis of unknown cause. Although most frequent in young Asian women, KFD has a worldwide distribution. Clinically, KFD is characterized by lymphadenitis of one or more lymph nodes, predominantly in the posterior cervical region, fever, and leukopenia in up to 50% of cases. Extranodal manifestations can occur, especially skin lesions and aseptic meningitides. Diagnosis is usually confirmed by analysis of samples from an excisional biopsy of the affected nodes. Histologically, the lesions affect the cortical and paracortical areas of the node. Characteristic features include focal necrosis predominantly in the paracortical region with abundant karyorrhectic debris and atypical mononuclear cells around the necrotic zone (crescent-shaped histiocytes, plasmacytoid monocytes, and small lymphocytes and immunoblasts, mostly CD3(+)/CD8(+)), most often with an intact lymph node capsule, an absence of neutrophils, and a paucity of plasma cells. KFD has been classified into three histological subtypes and is thought to progress from the proliferative type (> 50%) to the necrotizing type (30%) and finally resolve into the xanthomatous type (< 20%). Differential diagnoses should include malignant lymphoma, infectious diseases such as toxoplasmatic lymphadenitis, tuberculous lymphadenitis and cat scratch disease, and systemic lupus erythematosus (SLE). The cause of KFD is unknown: a viral infection has been suggested, but not demonstrated, possibly involving human herpes virus 8 or Epstein-Barr virus. Apoptotic cell death plays a role: proliferating CD8(+) T-lymphocytes act as both killers and victims in the apoptotic process via Fas and perforin pathways. The course is usually benign with resolution in a few months with the use of antiinflammatory drugs. Regular follow-up is required because SLE may develop several years after the onset of Kikuchi-Fujimoto disease.
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Hanaoka M, Tsukimori K, Hojo S, Abe Y, Mutou T, Muta K, Iwasa A, Yao T, Nakano H. B-Cell Lymphoma During Pregnancy Associated with Hemophagocytic Syndrome and Placental Involvement. ACTA ACUST UNITED AC 2007; 7:486-90. [PMID: 17875240 DOI: 10.3816/clm.2007.n.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a case of B-cell lymphoma during pregnancy associated with hemophagocytic syndrome and placental involvement. A 33-year-old Japanese woman developed pancytopenia, hepatosplenomegaly, and a high-grade fever for 2 weeks at 23 weeks of gestation. The demonstration of hemophagocytes in her bone marrow confirmed the diagnosis of hemophagocytic syndrome. She was referred at 25 weeks of gestation for evaluation of hemophagocytic syndrome. The screening for infection and autoimmune disease was negative. Clinical manifestation suggested malignant lymphoma as the underlying cause of hemophagocytic syndrome, but we could not confirm any lymphoma involvement in the bone marrow aspiration. Glucocorticoid therapy did not arrest the hemophagocytic process. Her general status worsened, and reduction of amniotic fluid was noted. At 28 weeks of gestation, we performed a Cesarean section because of fetal distress. Microscopic examination of placental specimen revealed diffuse infiltration of large, atypical lymphoid cells involving the intervillous space. Using immunohistochemical study, we made the diagnosis of B-cell lymphoma. R-CHOP (rituximab/cyclophosphamide/doxorubicin/vincristine/prednisone) chemotherapy was administered on the eighth postpartum day. After 2 cycles of R-CHOP chemotherapy, hematopoiesis became normal and hepatosplenomegaly almost completely disappeared. After 6 cycles of R-CHOP, the patient received autologous peripheral-blood stem cell transplantation, and she is currently in complete remission 1 year after diagnosis. The infant did well, without clinical or laboratory manifestations of malignant lymphoma. In cases with suspected malignancy associated with hemophagocytic syndrome during pregnancy, it is important to verify placental microscopic examination for evaluating the causative disease of hemophagocytic syndrome.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Cesarean Section
- Female
- Fetal Distress/diagnosis
- Fetal Distress/pathology
- Fetal Distress/therapy
- Gestational Age
- Humans
- Lymphohistiocytosis, Hemophagocytic/diagnosis
- Lymphohistiocytosis, Hemophagocytic/pathology
- Lymphohistiocytosis, Hemophagocytic/therapy
- Lymphoma, B-Cell/diagnosis
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/therapy
- Peripheral Blood Stem Cell Transplantation
- Placenta/pathology
- Pregnancy
- Pregnancy Complications, Hematologic/diagnosis
- Pregnancy Complications, Hematologic/pathology
- Pregnancy Complications, Hematologic/therapy
- Pregnancy Complications, Neoplastic/diagnosis
- Pregnancy Complications, Neoplastic/pathology
- Pregnancy Complications, Neoplastic/therapy
- Transplantation, Autologous
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Affiliation(s)
- Mio Hanaoka
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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28
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Gerritsen A, Lam K, Marion Schneider E, van den Heuvel-Eibrink MM. An exclusive case of juvenile myelomonocytic leukemia in association with Kikuchi's disease and hemophagocytic lymphohistiocytosis and a review of the literature. Leuk Res 2006; 30:1299-303. [PMID: 16487587 DOI: 10.1016/j.leukres.2005.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Revised: 12/30/2005] [Accepted: 12/30/2005] [Indexed: 11/29/2022]
Abstract
We present a case of juvenile myelomonocytic leukemia (JMML) accompanied by immune-mediated hemophagocytic lymphohistiocytosis (HLH) and Kikuchi's disease, both as a paraneoplastic phenomenon. As this combination, to the best of our knowledge, has not been described before, consensus on preferable treatment is lacking. Our patient was treated with prednisolone according to the few described cases of HLH and Kikuchi's disease in non-JMML patients, resulting in disappearance of the clinical symptoms.
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Affiliation(s)
- Annemieke Gerritsen
- Department of Pediatric Oncology/Hematology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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29
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Kucukardali Y, Solmazgul E, Kunter E, Oncul O, Yildirim S, Kaplan M. Kikuchi-Fujimoto Disease: analysis of 244 cases. Clin Rheumatol 2006; 26:50-4. [PMID: 16538388 DOI: 10.1007/s10067-006-0230-5] [Citation(s) in RCA: 228] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2006] [Revised: 01/24/2006] [Accepted: 01/25/2006] [Indexed: 12/21/2022]
Abstract
Kikuchi-Fujimoto Disease (KFD) was first described in Japan in 1972. The disease frequently mimics tuberculous lymphadenitis, malign lymphoma, and many other benign and malignant conditions. To our knowledge, there is no previous study comparing the clinical and laboratory characteristics of patients from different geographical parts of the world. We searched literature records beginning from 1991 and analyzed epidemiological, clinical, and laboratory data of 244 patients (including cases diagnosed in our institution) reported in 181 publications. Of the 244 cases, 33% were male and 77% were female. Mean age was 25 (1-64) and 70% was younger than 30. Most of the cases were reported from Taiwan (36%), USA (6.6%), and Spain (6.3%). Fever (35%), fatigue (7%) and joint pain (7%) were the most frequent symptoms, while lymphadenomegaly (100%), erythematous rashes (10%), arthritis (5%), hepatosplenomegaly (3%), leucopenia (43%), high erythrocyte sedimentation rate (40%), and anemia (23%) being the most common findings. KFD was associated with SLE (32 cases), non-infectious inflammatory diseases (24 cases), and viral infections (17 cases). SLE was more frequent in cases from Asia than Europe (28 and 9%, respectively). The disease was self-limiting in 156 (64%) and corticosteroid treatment was necessary in 16 (16%) of the cases. The mortality rate was 2.1%. Early diagnosis is crucial as the clinical and laboratory presentation generally imitates situations needing lengthy and costly diagnostic and therapeutic interventions. Additionally, association with SLE needs further investigation.
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Affiliation(s)
- Yasar Kucukardali
- Internal Medicine, Gata Haydarpasa Training Hospital, Istanbul, Turkey
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30
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Leyral C, Camou F, Perlemoine C, Caubet O, Pellegrin JL, Viallard JF. [Pathogenic links between Kikuchi's disease and lupus: a report of three new cases]. Rev Med Interne 2005; 26:651-5. [PMID: 15935519 DOI: 10.1016/j.revmed.2005.03.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Accepted: 03/29/2005] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto's disease is a rare anatomoclinical entity whose etiology remains unknown. It is mainly reported in young adult female, presenting with cervical lymphadenopathies, fever and asthenia. The diagnosis is based on the histological examination of a lymph node biopsy. The disease course is usually uneventful, but sometimes Kikuchi-Fujimoto's disease can reveal or evolve into a cutaneous or a systemic lupus. EXEGESIS We report three new cases of Kikuchi's disease: the first one mimicked a systemic lupus, the second one was associated with a lupus-like rash, and a the last one was a severe case with hemophagocytic syndrome and a primo-infection with Epstein-Barr virus revealing a systemic lupus erythematosus. CONCLUSION Clinical and biological follow-up of patients presenting with Kikuchi's disease is necessary to look for an association with a lupus. We discuss the pathogenic links between Kikuchi's disease and lupus.
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Affiliation(s)
- C Leyral
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, avenue de Magellan, 33604 Pessac, France
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Velasco Malagón MJ, Zambrana García JL, Adarraga Cansino MD, Rosa Jiménez F. Enfermedad de Kikuchi-Fujimoto y tuberculosis pulmonar, una asociación poco frecuente. Rev Clin Esp 2003; 203:508-9. [PMID: 14563248 DOI: 10.1016/s0014-2565(03)71340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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