Histiocytic medullary reticulosis

A clinical analysis of 52 adult patients with hemophagocytic syndrome: the prognostic significance of the underlying diseases

We retrospectively analyzed 52 adult patients with hemophagocytic syndrome (HPS). The underlying diseases were heterogeneous, including malignant lymphoma (lymphoma-associated hemophagocytic syndrome [LAHS]) in 26 patients, systemic lupus erythematosus in 3 patients, viral infections in 7 patients, and bacteria] or fungal infections in 6 patients. More than 83% of patients received prednisolone as an initial treatment. Multiple-agent chemotherapies (cyclophosphamide, doxorubicin, and vincristine) were administered to 96% of LAHS patients after a histopathological diagnosis of lymphoma. HPSs were controllable and remissions were achieved except for those patients with LAHS, fulminant Epstein-Barr virus-associated HPS, and an immunosuppressive state. Twenty-one (81%) of the LAHS patients had uncontrollable HPS and died of multiple organ failure and disseminated intravascular coagulation. The median survival time of LAHS patients was 83 days. In contrast, 3 (12%) of the other HPS patients died of multiple organ failure within 44 days.The clinical manifestations and the laboratory findings of LAHS and the other HPSs were too variable to establish the prognosis based only on the findings at the onset of HPS. The prognostic factors of adult HPS were found to be the underlying diseases, notably malignant lymphoma and infections, accompanied by the immunosuppressive state.

Polymerase chain reaction amplification of archival material for Epstein-Barr virus, cytomegalovirus, human herpesvirus 6, and parvovirus B19 in children with bone marrow hemophagocytosis

Bone marrow hemophagocytosis may occur as an incidental finding, or it may be a manifestation of a systemic and potentially lethal disorder. When systemic, the proliferation is termed hemophagocytic lymphohistiocytosis (HLH), a clinicopathologic entity characterized by a widespread proliferation of benign hemophagocytic histiocytes, fever, pancytopenia, deranged liver function, and frequently coagulopathy and hepatosplenomegaly. A variety of infectious agents, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus 6 (HHV6), and parvovirus B19 (PVB19), have been associated with HLH, but the relative frequency of each using one technique has not been evaluated. In addition, infectious causes of incidental bone marrow hemophagocytosis, not occurring in the setting of HLH, have not been evaluated. Review of bone marrow reports from bone marrow examinations done between December 1986 and June 1997 showed that 20 children aged 2 months to 15 years had bone marrow examinations that indicated hemophagocytosis. Archival materials from 19 patients were successfully retrieved, and DNA was extracted from archived unstained coverslips with subsequent polymerase chain reaction for EBV, CMV, HHV6, and PVB19 genomic DNA. DNA extracted from 16 bone marrow specimens of age-matched children was used as negative controls. Eleven of the 19 patients fulfilled the clinical and pathological criteria for HLH; the remaining eight patients had isolated hemophagocytosis without a systemic presentation. Viral DNA was detected in 8 of 11 patients with HLH but in none of eight patients with isolated hemophagocytosis. EBV was present in five of the bone marrows, followed in frequency by HHV6, CMV, and PVB19. Infection with more than one agent was present in three patients. Only one control patient was positive for HHV6 DNA; the remaining control patients were negative for all viruses. Viral infection, detected by PCR analysis of bone marrow, is a common finding in patients with HLH but not in patients with isolated bone marrow hemophagocytosis. This technique may provide another marker to aid in the diagnosis of HLH and suggests a different cause of hemophagocytosis occurring in patients with and without HLH.

Tuberculosis-associated fatal hemophagocytic syndrome in a patient with lymphoma treated with fludarabine

A patient with a stage IV high-grade non-Hodgkin's lymphoma who developed a fatal hemophagocytic syndrome is presented: When the patient had achieved complete remission and receiving fludarabine and chlorambucil/prednisone, she developed miliary tuberculosis, the CD4+ T-cell count then being 50/microL; the hemophagocytic syndrome ensuing at this point was fatal. Speculations about the predisposing factors that could have led to this complication are discussed focusing on the severe cellular immunosuppression which developed probably related to the use of fludafabine: it could be useful in the future to use anti-tuberculous prophylaxis in selected patients treated with this purine nucleoside analog.

A child case of haemophagocytic syndrome associated with cryptococcal meningoencephalitis

A previously healthy 12-year-old Japanese girl developed meningoencephalitis due to Cryptococcus neoformans. During the course of her illness she suffered persistent high fever, severe pancytopenia, hypercytokinemia and liver dysfunction. Laboratory findings, including results of a bone marrow examination, strongly indicated complication by haemophagocytic syndrome (HPS). The preceding cryptococcal infection was thought to be a cause of the HPS because no other viral or bacterial infection could be confirmed. The girl died of acute respiratory failure during the progressive course of HPS. This may be the first reported case of HPS due to cryptococcal infection in an otherwise healthy child.

Peripheral T-cell lymphoma presenting as hemophagocytic syndrome

Three patients with peripheral T-cell lymphoma presenting with pyrexia, wasting, hepatosplenomegaly and pancytopenia in the absence of myelophthisic lymphomatous involvement are reported. Early in the course of the disease when there was no significant lymphadenopathy, these cases created enormous diagnostic confusion. Although the clinical features were suggestive of malignant histiocytosis (MH), marrow findings showed phagocytic histiocytes which did not appear atypical, and the criteria for diagnosis of MH could not be satisfied. Lymph node enlargement was detected only after 14, 5, and 8 weeks from the onset of symptoms, and the diagnosis of T-lymphoma was then made on lymph node biopsies. Treatment with multiple agent chemotherapy was attempted. Two patients died 3 days and 11 weeks after treatment was started and the third was lost to follow-up. In contrast with most of the cases reported in the literature, our cases show that a reactive hemophagocytic syndrome can be an early and prominent manifestation of an underlying T-cell lymphoma. Differentiation from other causes of hemophagocytic syndrome can be difficult and lack of histological proof of malignancy in the initial stage often delays definitive diagnosis and treatment.

Reactive hemophagocytic syndrome: a study of 7 fatal cases

Reactive hemophagocytic syndrome is a clinico-pathologic entity characterized by systemic proliferation of non-neoplastic histiocytes showing phagocytosis of hemopoietic cells, resulting in blood cytopenia. It is best known to be associated with virus infection, but other associated diseases have also been implicated. The clinical and pathological findings of 7 fatal cases are described. The syndrome affected both sexes of a wide age range, and all patients had fever. Significant laboratory findings were blood cytopenia, abrupt drop in the blood cell counts, deranged liver function tests and abnormal coagulation profile. The associated diseases were diverse: two patients had bacterial infection; two had peripheral T-cell lymphoma; one had disseminated undifferentiated carcinoma of the ovary; one had both tuberculosis and disseminated nasopharyngeal carcinoma, and one had no obvious underlying disease. It is postulated that lymphokines secreted by lymphoid cells or tumor cells may be responsible for the systemic activation of histiocytes. The differential diagnosis from malignant histiocytosis is discussed.

Tuberculosis-associated hemophagocytic syndrome. A systemic process

Virus-associated hemophagocytic syndrome has been recently identified as a benign, reactive histiocytic proliferation distinct from Rappaport's malignant hystiocytosis. Other etiologic agents, including different bacteria, have also been identified. Three autopsy cases of hemophagocytic syndrome associated to acute tuberculous sepsis are presented. Benign histiocytic proliferation with striking hemophagocytosis was present in a disseminated, multisystemic pattern in all three cases. A relationship between systemic histiocytic proliferation and an anergic status in these patients is suggested.

Mediastinal germ cell tumour associated with malignant histiocytosis and high rubella titres

Two further cases of a haematological malignancy are reported in patients with mediastinal germ cell tumours. Two young men developed bone marrow infiltration with histiocytes showing erythrophagocytosis shortly after subtotal excision of a malignant teratoma of the anterior mediastinum. Serial viral titres showed a rise in rubella antibody titres by haemoagglutination inhibition in both cases, antirubella IgG (ELISA) in one case and rubella RH zone in the other, in the absence of detectable IgM rubella antibodies. In case 1 a diagnosis of virus associated haemophagocytic syndrome was made and he was treated with interferon and steroids. In case 2 the diagnosis was initially idiopathic thrombocytopenia purpura but he deteriorated on steroids, and was subsequently unsuccessfully treated with chemotherapy and gamma globulin infusions. The disease ran a rapid downhill course with progressive marrow failure and they both died 5 months after diagnosis. Review of the presenting histology, the progressive course of the disease and post mortem histology, suggests that they had malignant histiocytosis. The association between mediastinal teratoma and haematological malignancy is of biological importance. Serial viral titres should be measured in patients with malignant histiocytosis to see if there is a raised rubella titre. Such viral studies are also warranted where there is an association between a mediastinal germ cell tumour and haematological malignancy.

Systemic babesiosis. Another cause of the hemophagocytic syndrome

Hemophagocytosis is a pathologic finding in a variety of infectious diseases associated with peripheral pancytopenia. In addition, hemophagocytosis is a prominent finding in malignant histiocytosis, a primary disorder of the monocyte-macrophage system. Systemic babesiosis is a rare parasitic disorder associated with intraerythrocytic parasites in the peripheral blood. There has been no description of the marrow findings in this disorder. A patient is described who had systemic babesiosis and prominent hemophagocytosis that disappeared after appropriate antiparasitic therapy. Systemic babesiosis should be considered in the differential diagnosis of hemophagocytosis.

Bacteria-associated hemophagocytic syndrome

Histiocytic medullary reticulosis (HMR) was originally defined as a neoplastic disorder. Some cases reported as HMR have been characterized by a systemic proliferation of mature histiocytes showing hemophagocytosis, bone marrow necrosis, pancytopenia, hepatitis, and coagulopathy. Clinically, these patients have fever and constitutional symptoms and often have hepatosplenomegaly and lymphadenopathy. Although there is a high mortality rate, this process appears to be reactive and has been associated with active viral infection. Similar cases have been briefly described that were associated with other agents or disease processes, but concomitant viral infections were not excluded. Three characteristic examples of this hemophagocytic syndrome that were associated with bacterial sepsis are described. Active infection by those viruses that have previously been associated with the syndrome was excluded. It appears that the hemophagocytic syndrome may be associated with various types of active disseminated infections.

Association of T cell acute lymphoblastic leukemia and histiocytic medullary reticulosis

Seventeen reported cases of acute lymphoblastic leukemia that terminated in a clinical picture of histiocytic medullary reticulosis were reviewed. Using the presence of T cell markers, mediastinal mass, or very high initial white blood cell count as suggestive of T cell acute lymphoblastic leukemia, nine of 13 evaluable cases fulfilled such criteria. This review raises the possibility that the histiocytic medullary reticulosis appearing in the course of T cell acute lymphoblastic leukemia is the result of lymphokine production by the leukemic cells.