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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) has well been studied as a genetic disorder in children (primary HLH). Mutations in the regulatory complex of the cellular immune synapse lead to a loss of function of cytotoxic T‑cells and natural killer cells with excessive inflammation based on a cytokine storm. During the last decade, an increasing number of adult HLH patients without a family history of HLH (secondary or acquired HLH) have been reported. Various triggers - infections, malignancies or autoimmune diseases - result in an acquired loss of function of these cells and a sepsis-like disease. Missed or late diagnosis is believed to be a major cause of the high mortality. OBJECTIVES To describe the current knowledge on HLH and to raise awareness. MATERIALS AND METHODS Analysis of case reports, current studies, and expert recommendations. RESULTS Increased vigilance in identifying the adult form of HLH resulted in an increasing number of case reports over the past few years. HLH patients typically present with a clinical phenotype resembling severe sepsis or septic shock with fever, cytopenia, and organomegaly, which do not or insufficiently respond to anti-infective treatment. Early recognition of HLH distinction from sepsis, and prompt initiation of treatment - which is fundamentally different from sepsis - are crucial for improved outcome. A promising diagnostic parameter is ferritin, which has gained sufficient specificity, but only in the context of the triad of fever, cytopenia, and organomegaly. Treatment of adult HLH patients requires immunosuppression, with strict therapeutic guidance derived from the triggering disease. CONCLUSIONS Because of the similar clinical presentation to that of sepsis, HLH is often not recognized, resulting in a fatal outcome. In "sepsis" patients on the ICU with deterioration despite a standard of care, HLH needs to be considered by testing for ferritin when considering differential diagnoses. The complexity of the illness requires interdisciplinary patient care with specific integration of the hematologist in the diagnostic workup and therapeutic management, because of the frequent use of chemotherapy-based immunosuppression.
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Pucheu-Haston CM, Del Piero F. Equine multi-systemic eosinophilic epitheliotropic disease. EQUINE VET EDUC 2013. [DOI: 10.1111/eve.12107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- C. M. Pucheu-Haston
- Departments of Veterinary Clinical Sciences; Louisiana State University; Louisiana USA
| | - F. Del Piero
- Pathobiology; School of Veterinary Medicine; Louisiana State University; Louisiana USA
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Clinical analysis and prognostic significance of lymphoma-associated hemophagocytosis in peripheral T cell lymphoma. Ann Hematol 2012; 92:481-6. [PMID: 23238896 PMCID: PMC3590418 DOI: 10.1007/s00277-012-1644-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 11/25/2012] [Indexed: 11/04/2022]
Abstract
This study aims to retrospectively analyze the clinical characteristics, treatments, and prognosis of aggressive peripheral T cell lymphoma (PTCL) patients with a lymphoma-associated hemophagocytosis syndrome (LAHS). We compared the clinical features and the overall survival (OS) rates of 159 PTCL patients with and without LAHS as well as the treatment outcomes of these patients with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or intensive chemotherapy regimens. We observed that in 23 % (36/159) patients PTCL was associated with LAHS. Different subtypes of PTCL in LAHS patients were diagnosed and peripheral T cell lymphoma, not otherwise specified (PTCL-NOS) was the main subtype (78 %). The median survival rates of the LAHS and non-LAHS groups were 3 and 16 months, respectively. The elevated rates of serum β2-microglobulin, ferritin, fasting triglycerides, and hypofibrinogen levels were higher in the LAHS group, so were bone marrow involvement, liver dysfunction, hepatosplenomegaly, and B symptoms. Three patients who were treated with a plasma exchange had a longer survival time. There was no statistically significant difference in the OS rates between the intensive chemotherapy and CHOP regimen groups (P > 0.05). PTCL patients with LAHS had a poorer prognosis. Awareness of the clinical symptoms and laboratory findings are crucial in order to diagnose LAHS in an early stage and repeated biopsies of multiple bone marrows from different locations in those patients without enlargement of superficial lymph nodes are necessary to improve the diagnosis. Intensive chemotherapy due to its severe toxicity was not obviously advantageous for the OS rate compared to the CHOP regimen.
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Roufosse F, Garaud S, de Leval L. Lymphoproliferative disorders associated with hypereosinophilia. Semin Hematol 2012; 49:138-48. [PMID: 22449624 DOI: 10.1053/j.seminhematol.2012.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypereosinophilia, defined as peripheral blood eosinophil counts > 1,500/μL, may complicate the course of various lymphoproliferative disorders. Among these, Hodgkin lymphoma (HL) and certain peripheral T-cell lymphomas (PTCLs) derived from CD4 cells, including Sezary syndrome (SS), adult T-cell leukemia/lymphoma (ATLL), and angioimmunoblastic T-cell lymphoma (AITL), are most commonly associated with increased reactive eosinophilopoiesis. Rarely, marked hypereosinophilia (HE) may occur in the setting of acute B-cell lymphoblastic leukemia, with a substantial impact on disease course. The mechanisms leading to blood and tissue eosinophilia in the setting of lymphoproliferative disorders, as well as the clinical complications and prognostic implications of hypereosinophilia, are discussed in this review.
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Affiliation(s)
- Florence Roufosse
- Department of Internal Medicine, Hôpital Erasme, Université Libre de Bruxelles, 808 Route de Lennik, B-1070 Brussels, Belgium.
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Mehta V, Hameed S, Balachandran C, Roy A. Peripheral T Cell Lymphoma Presenting with Hypereosinophilia. Med J Armed Forces India 2011; 64:89-91. [PMID: 27408095 DOI: 10.1016/s0377-1237(08)80166-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 08/25/2007] [Indexed: 10/18/2022] Open
Affiliation(s)
- V Mehta
- Assistant Professor, Kasturba Medical College, Manipal, Karnataka
| | - S Hameed
- Postgraduate Student, Kasturba Medical College, Manipal, Karnataka
| | - C Balachandran
- Professor and Head (Department of Skin & STD), Kasturba Medical College, Manipal, Karnataka
| | - A Roy
- Associate Professor (Department of Pathology), Kasturba Medical College, Manipal, Karnataka
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Romero Fernández E, Pardo JRP, Doyle A, Albendea MC, de la Rúa AR. Hemophagocytic syndrome associated NK/T nasal type lymphoma presenting as hypereosinophilic syndrome: a case report and literature review. Leuk Res 2011; 35:e97-9. [PMID: 21501869 DOI: 10.1016/j.leukres.2010.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 12/04/2010] [Accepted: 12/20/2010] [Indexed: 12/25/2022]
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Dearden CE, Johnson R, Pettengell R, Devereux S, Cwynarski K, Whittaker S, McMillan A. Guidelines for the management of mature T-cell and NK-cell neoplasms (excluding cutaneous T-cell lymphoma). Br J Haematol 2011; 153:451-85. [PMID: 21480860 DOI: 10.1111/j.1365-2141.2011.08651.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The peripheral T-cell neoplasms are a biologically and clinically heterogeneous group of rare disorders that result from clonal proliferation of mature post-thymic lymphocytes. Natural killer (NK) cell neoplasms are included in this group. The World Health Organization classification of haemopoietic malignancies has divided this group of disorders into those with predominantly leukaemic (disseminated), nodal, extra-nodal or cutaneous presentation. They usually affect adults and are more commonly reported in males than in females. The median age at diagnosis is 61 years with a range of 17-90 years. Although some subtypes may follow a relatively benign protracted course most have an aggressive clinical behaviour and poor prognosis. Excluding anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL), which has a good outcome, 5-year survival for other nodal and extranodal T-cell lymphomas is about 30%. Most patients present with unfavourable international prognostic index scores (>3) and poor performance status. The rarity of these diseases and the lack of randomized trials mean that there is no consensus about optimal therapy for T- and NK-cell neoplasms and recommendations in this guideline are therefore based on small case series, phase II trials and expert opinion.
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Nozawa K, Kaneko H, Itoh T, Katsura Y, Noguchi M, Suzuki F, Takasaki Y, Ogawa H, Takamori K, Sekigawa I. Synchronous malignant B-cell lymphoma and gastric tubular adenocarcinoma associated with paraneoplastic cutaneous vasculitis: hypereosinophilic syndrome with mixed cryoglobulinemia is an important sign of paraneoplastic syndrome. Rare Tumors 2009; 1:e42. [PMID: 21139921 PMCID: PMC2994459 DOI: 10.4081/rt.2009.e42] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 09/26/2009] [Accepted: 10/01/2009] [Indexed: 02/08/2023] Open
Abstract
Gastric adenocarcinoma developing concomitantly with a lymphoma is rare. Furthermore, B-cell lymphoma, originating from lymph nodes, with eosinophilia is extremely rare. We report here a case with a synchronous diffuse large B-cell lymphoma (DLBCL) and an early adenocarcinoma of the stomach. In addition, this case seemed to be associated with paraneoplastic cutaneous vasculitis caused by hypereosinophilic syndrome (HES) with mixed cryoglobulinemia (MC). Many neoplastic diseases that affect internal organs display cutaneous manifestations, which may be the presenting signs and symptoms of the underlying malignancy. In particular, the association between cutaneous vasculitis and malignancy has been widely reviewed, and recently neoplasms have been suggested to produce antigens and the resultant immune complex formations, activating the serum complement, thus cause paraneoplastic vasculitis. In this case, severe eosinophilia and cryoglobulinemia with low complements were observed in a laboratory test. A biopsy specimen from a skin lesion revealed leukocytoclastic vasculitis with severe perivascular infiltration of eosinophils. The cutaneous vasuculitis was considered to be a manifestation of HES with MC, although there were no etiological factors of HES and MC. Therefore, the vasculitis seems to be a symptom of paraneoplastic syndrome in this case. Our finding suggests that the potential presence of malignancies should be kept in mind as a possible underlying disorder especially in the presence of HES with MC; this possibility is interesting also as regards at least part of the pathogenesis for paraneplastic syndrome.
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Affiliation(s)
- Kazuhisa Nozawa
- Department of Internal Medicine and Rheumatology, Juntendo University Urayasu Hospital, Chiba, Japan
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My LT, Lien LB, Hsieh WC, Imamura T, Anh TNK, Anh PNL, Hung NT, Tseng FC, Chi CY, Dao NTH, Le DTM, Thinh LQ, Tung TT, Imashuku S, Thuong TC, Su IJ. Comprehensive analyses and characterization of haemophagocytic lymphohistiocytosis in Vietnamese children. Br J Haematol 2009; 148:301-10. [PMID: 19863536 DOI: 10.1111/j.1365-2141.2009.07957.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a fatal haematological disorder with diverse aetiology. This prospective study was undertaken to characterize HLH cases in Vietnamese children. Clinical and laboratory data, genetic analyses and outcome of the HLH patients were analysed. A total of 33 patients were enrolled from March 2007 to December 2008, with a median age of 3 years. Mutations of the SH2D1A (SAP) and PRF1 genes were detected in one patient, respectively. The virus association was high, up to 63.6% (21/33), including Epstein-Barr virus (19/33), cytomegalovirus (2/33) and dengue virus (2/33). Five patients had malignant lymphoma and two had autoimmune diseases. Twenty-eight patients were treated according to the HLH-2004 protocol. The first response rate was 64.3% (18/28), with an early death rate of 35.7% (10/28). High levels of interferon-gamma, interleukin-10, MIG and interferon-inducible protein-10 (IP-10) were associated with early mortality (P < 0.05). Reactivation among the responders was high (9/18) and the uneventful resolution was low (3/18) after a median follow-up of 35 weeks. In conclusion, the majority of HLH cases are associated with virus infections in Vietnamese children. Familial HLH is rare. The frequent reactivation and high mortality demands a more appropriate therapeutic regimen in tropical areas like Vietnam.
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Affiliation(s)
- Lam T My
- Department of Clinical Haematology, Children Hospital, Ho-Chi-Minh City, Vietnam
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Tong H, Ren Y, Liu H, Xiao F, Mai W, Meng H, Qian W, Huang J, Mao L, Tong Y, Wang L, Qian J, Jin J. Clinical characteristics of T-cell lymphoma associated with hemophagocytic syndrome: Comparison of T-cell lymphoma with and without hemophagocytic syndrome. Leuk Lymphoma 2009; 49:81-7. [DOI: 10.1080/10428190701713630] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Choi W, Park YH, Paik KH, Chang YH, Lee SS, Ryoo BY, Yang SH. Peripheral T-cell lymphoma-unspecified (PTCL-U) presenting with hypereosinophilic syndrome and pleural effusions. Korean J Intern Med 2006; 21:57-61. [PMID: 16646567 PMCID: PMC3891066 DOI: 10.3904/kjim.2006.21.1.57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hypereosinophilic syndrome (HES) is a clinical disorder characterized by persistent eosinophilia and systemic involvement, in which a specific causative factor for the eosinophilia cannot be verified during a certain period of time. There have been only a few reported cases of this syndrome associated with malignant lymphoma. We report a case of peripheral T-cell lymphoma-unspecified with hypereosinophilic syndrome. The patient was a 42-year-old woman with an uncontrolled fever and a sore throat. Eosinophilia was observed on the peripheral blood smear. We confirmed the diagnosis by bone marrow and liver biopsies:. A bone marrow aspiration demonstrated markedly increased eosinophils (24.8%), and a liver biopsy demonstrated infiltration by scattered eosinophils and atypical lymphoid cells, which were confirmed to be T-cell lymphoma cells. This case was a distinctive presentation of peripheral T-cell lymphoma with hypereosinophilic syndrome, probably due to a paraneoplastic condition.
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Affiliation(s)
- Won Choi
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Yeon Hee Park
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Kwang Hyun Paik
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Yoon Hwan Chang
- Department of Laboratory Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Seung-Sook Lee
- Department of Pathology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Baek-Yeol Ryoo
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sung Hyun Yang
- Department of Internal Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
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