1
|
Rolsdorph LÅ, Mosevoll KA, Helgeland L, Reikvam H. Concomitant Hemophagocytic Lymphohistiocytosis and Cytomegalovirus Disease: A Case Based Systemic Review. Front Med (Lausanne) 2022; 9:819465. [PMID: 35514747 PMCID: PMC9063453 DOI: 10.3389/fmed.2022.819465] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/25/2022] [Indexed: 12/25/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an immune mediated life-threatening condition. It is driven by an overactivation of the immune system and causes inflammatory tissue damage potentially leading to organ failure and death. Primary HLH is caused by genetic mutations, while secondary HLH is triggered by external factors. Viral infections are a well-known cause of secondary HLH. Cytomegalovirus (CMV) is a virus in the herpes family known to cause HLH in rare cases. Methods We report a recent case of CMV-induced HLH, followed by a systematic review of described cases of this rare disease entity, through a structured search in the medical database PubMed. All articles were assessed on a predetermined set of inclusion criteria. Results A total of 74 patients (age > 18 years) with CMV-related HLH were identified, 29 men, 42 women, and three patients with unspecified gender. Median age was 37.5 years (range 18-80). Sixty-six patients (88%) had one or more comorbid conditions and 22 patients (30%) had inflammatory bowel disease (IBD), the most frequent comorbidity. Forty patients (54%) received some form of immunomodulating treatment prior to HLH development. The general treatment approach was in general dual, consisting of antiviral treatment and specific immunomodulating HLH treatment approaches. Treatment outcome was at 77% survival, while 23% had fatal outcome. Conclusion The findings highlight the importance of early diagnostic work up and treatment intervention. Ability to recognize the characteristic clinical traits and perform specific HLH diagnostic workup are key factors to ensure targeted diagnostic work and treatment intervention for this patient group.
Collapse
Affiliation(s)
- Linn Åsholt Rolsdorph
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Knut Anders Mosevoll
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Helgeland
- Department of Medical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
2
|
Sandler RD, Carter S, Kaur H, Francis S, Tattersall RS, Snowden JA. Haemophagocytic lymphohistiocytosis (HLH) following allogeneic haematopoietic stem cell transplantation (HSCT)-time to reappraise with modern diagnostic and treatment strategies? Bone Marrow Transplant 2020; 55:307-316. [PMID: 31455895 PMCID: PMC6995779 DOI: 10.1038/s41409-019-0637-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/28/2019] [Accepted: 06/07/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Robert David Sandler
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.
| | - Stuart Carter
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Harpreet Kaur
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Sebastian Francis
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Rachel Scarlett Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - John Andrew Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| |
Collapse
|
3
|
Ito M, Fujino M. Macrophage‐mediated complications after stem cell transplantation. Pathol Int 2019; 69:679-687. [DOI: 10.1111/pin.12865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 09/17/2019] [Indexed: 01/16/2023]
Affiliation(s)
- Masafumi Ito
- Department of PathologyJapanese Red Cross, Nagoya First Hospital Aichi Japan
| | - Masahiko Fujino
- Department of PathologyJapanese Red Cross, Nagoya First Hospital Aichi Japan
| |
Collapse
|
4
|
My jamais vu in post allogeneic hematopoietic cell transplant: a review on secondary hemophagocytosis in adults. Bone Marrow Transplant 2019; 55:867-872. [PMID: 31611631 DOI: 10.1038/s41409-019-0711-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 11/08/2022]
Abstract
Post allogenic hematopoietic cell transplant (HCT) hemophagocytic lymphohistiocytosis (HLH) is an aggressive disease with unknown etiology. It has a poorly understood pathophysiology and poor outcome if untreated early. It's a state of hypercytokinemia. There are many proposed diagnostic criteria for Post HCT HLH. It usually occurs early in the first 2-6 weeks after allogeneic HCT but can present late. The incidence is highest among cord blood transplant compared with other sources of stem cells with a higher incidence in HLA mismatch donors. Post HCT HLH has a marked low survival rate, when compared with Non-HLH post HCT patients and specifically poor outcome is associated in patients with liver dysfunction, graft failure, and those with endothelial complications. Steroid is the mainstay treatment which can be followed up by cyclosporine and etoposide though an optimal therapy is not known. Intravenous immunoglobulin (IVIg) has been tried in virus associated HLH. Second bone marrow transplant is a rescue procedure in patient with HLH due to graft failure, though a very careful selection of individual patients is mandatory. It has been recently found that etoposide based conditioning regimen may reduce HLH post HCT. A prospective study on post HCT HLH are needed to evaluate this unrecognized condition.
Collapse
|
5
|
Ladeb S, Ben Abdejlil N, Fakhfakh N, Lakhal A, Belloumi D, Ben Hamed L, Kallel A, Torjman L, El Fatimi R, Hmida S, Kallel K, Ben Othman T. Plasmodium falciparum infection transmitted by transfusion: A cause of hemophagocytic syndrome after bone marrow tranplantation in a non-endemic country. Transpl Infect Dis 2018; 20:e12887. [PMID: 29573075 DOI: 10.1111/tid.12887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 01/09/2018] [Accepted: 01/27/2018] [Indexed: 12/20/2022]
Abstract
A 27-year-old man with severe aplastic anemia underwent bone marrow transplantation from his HLA identical brother in July 2016. Conditioning included ATGAM 30 mg/kg for 3 days and Cyclophosphamide 50 mg/kg for 4 days. The patient received several platelet and red blood cell transfusions before and after the conditioning. The patient received broad spectrum antibiotics and caspofungin because persistant febrile neutropenia without bacteriological or mycological documentation. Hemophagocytic syndrome was diagnosed on day +12. Steroids at 1 mg/kg were started on day +12. Fever resolved the same day but resumed 3 days later associated to intravascular hemolysis with no schizocytes on blood smears and negative DAT. Thick blood film smears performed on day +26 revealed Plasmodium falciparum parasites (parasitemia = 20%). Except the level of parasitemia, there were no signs of gravity. Quinine was started on day 26 at a loading dose of 15 mg/kg followed by 8 mg/kg three times a day for 20 doses. Fever vanished after 2 days. Parasitemia cleared in 3 days and remained negative thereafter. Investigations revealed that the patient was transfused by a red cell unit harvested in a voluntary donor native of a malaria endemic country. PCR for P. falciparum performed in this donor in the frame of investigations was positive. The patient is alive with a normal blood count 1 year after BMT.
Collapse
Affiliation(s)
- Saloua Ladeb
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Nour Ben Abdejlil
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Najla Fakhfakh
- Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia.,Laboratoire de Parasitologie et de Mycologie, Hôpital la Rabta, Tunis, Tunisia
| | - Amel Lakhal
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Dorra Belloumi
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | | | - Aicha Kallel
- Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia.,Laboratoire de Parasitologie et de Mycologie, Hôpital la Rabta, Tunis, Tunisia
| | - Lamia Torjman
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Rym El Fatimi
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Slama Hmida
- Centre National de Transfusion Sanguine, Tunis, Tunisia
| | - Kalthoum Kallel
- Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia.,Laboratoire de Parasitologie et de Mycologie, Hôpital la Rabta, Tunis, Tunisia
| | - Tarek Ben Othman
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.,Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisia
| |
Collapse
|
6
|
Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
Collapse
Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | |
Collapse
|
7
|
Ariza-Heredia EJ, Nesher L, Chemaly RF. Cytomegalovirus diseases after hematopoietic stem cell transplantation: a mini-review. Cancer Lett 2014; 342:1-8. [PMID: 24041869 DOI: 10.1016/j.canlet.2013.09.004] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/08/2013] [Indexed: 02/03/2023]
Abstract
Cytomegalovirus (CMV) infection remains a significant complication after hematopoietic stem cell transplantation (HSCT) and may have a deleterious impact on the overall outcome after transplantation. In addition to the direct effects of CMV infection, tissue-invasive CMV diseases may be associated with increased risk of graft versus host disease, myelosuppression, and invasive bacterial and fungal infections. Because of these direct and indirect adverse effects, prevention of CMV infection, mostly through pre-emptive therapy, is one of the essential strategies that may improve outcomes of HSCT recipients. Management of CMV infection relies mainly on intravenous (IV) antiviral therapy with ganciclovir and foscarnet, with or without IV polyclonal immunoglobulins. Although viral resistance remains rare, better tolerated antiviral agents with less serious side effects are needed, and a few will be evaluated in phase III clinical trials in the near future.
Collapse
Affiliation(s)
- Ella J Ariza-Heredia
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | | |
Collapse
|
8
|
Ohkuma K, Saraya T, Sada M, Kawai S. Evidence for cytomegalovirus-induced haemophagocytic syndrome in a young patient with AIDS. BMJ Case Rep 2013; 2013:bcr-2013-200983. [PMID: 24068515 DOI: 10.1136/bcr-2013-200983] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A 29-year-old man with HIV infection was referred to our department because of a 1-month history of low-grade fever and fatigue. Bone marrow aspiration and biopsy showed findings consistent with haemophagocytic syndrome (HPS), and immunohistochemical assessment showed cytomegalovirus (CMV) infection. HIV-associated HPS can occur at any stages of HIV disease and requires diverse differential diagnosis. CMV-associated HPS (CMV-HPS) in patients with HIV infection is relatively rare, but the present case showed that the clinicians should consider the possibility of CMV-HPS as a clinical feature of CMV infection.
Collapse
Affiliation(s)
- Kosuke Ohkuma
- Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | | | | | | |
Collapse
|
9
|
Kobayashi R, Tanaka J, Hashino S, Ota S, Torimoto Y, Kakinoki Y, Yamamoto S, Kurosawa M, Hatakeyama N, Haseyama Y, Sakai H, Sato K, Fukuhara T. Etoposide-containing conditioning regimen reduces the occurrence of hemophagocytic lymphohistiocytosis after SCT. Bone Marrow Transplant 2013; 49:254-7. [PMID: 24037021 DOI: 10.1038/bmt.2013.145] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/09/2013] [Accepted: 08/09/2013] [Indexed: 11/09/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease of severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages that secrete high amounts of inflammatory cytokines. HLH occurring after SCT is difficult to diagnose. It is characterized by severe clinical manifestations and high mortality. Despite current therapeutic approaches, outcomes remain poor. We analyzed the incidence and risk factors of HLH after SCT and the response to treatment and prognosis of 554 patients with HLH after SCT. The cumulative incidence of HLH after SCT was 4.3% (24/554). Use of etoposide in the conditioning regimen was only factor that reduced HLH after SCT (P=0.027). All patients who received autologous transplantation were successfully treated. Patients with liver dysfunction (for example, high total bilirubin level, prolonged prothrombin time and high level of fibrinogen degradation products) had a poor response to treatment for HLH. Physicians should be cautious of HLH, while not using etoposide for conditioning regimen.
Collapse
Affiliation(s)
- R Kobayashi
- Department of Pediatrics, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - J Tanaka
- Stem Cell Transplantation Center, Hokkaido University Hospital, Sapporo, Japan
| | - S Hashino
- Stem Cell Transplantation Center, Hokkaido University Hospital, Sapporo, Japan
| | - S Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Y Torimoto
- Third Department of Internal Medicine, Asahikawa Medical College, Asahikawa, Japan
| | - Y Kakinoki
- Department of Hematology, Asahikawa City Hospital, Asahikawa, Japan
| | - S Yamamoto
- Department of Hematology, Sapporo City General Hospital, Sapporo, Japan
| | - M Kurosawa
- Department of Hematology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - N Hatakeyama
- Department of Pediatrics, Sapporo Medical College, Sapporo, Japan
| | - Y Haseyama
- Department of Hematology, KKR Sapporo Medical Center, Tonan Hospital, Sapporo, Japan
| | - H Sakai
- Department of Hematology, Teine Keijinkai Hospital, Sapporo, Japan
| | - K Sato
- Department of Hematology, Hokkaido P.W.F.A.C Asahikawa-Kosei General Hospital, Asahikawa, Japan
| | - T Fukuhara
- Department of Palliative Care Medicine, Hokkaido P.W.F.A.C Sapporo-Kosei General Hospital, Sapporo, Japan
| |
Collapse
|
10
|
Asano T, Kogawa K, Morimoto A, Ishida Y, Suzuki N, Ohga S, Kudo K, Ohta S, Wakiguchi H, Tabuchi K, Kato S, Ishii E. Hemophagocytic lymphohistiocytosis after hematopoietic stem cell transplantation in children: a nationwide survey in Japan. Pediatr Blood Cancer 2012; 59:110-4. [PMID: 22038983 DOI: 10.1002/pbc.23384] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/09/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is associated with hypercytokinemia in children. Although HLH can be also observed after hematopoietic stem cell transplantation (HSCT), the incidence and clinical features of HLH after HSCT remain obscure. PROCEDURE The clinical features of HLH after HSCT (post-HSCT HLH) were investigated in children with malignancies, immune deficiencies, or aplastic anemia. The HLH/Langerhans Cell Histiocytosis (LCH) Committee of the Japanese Society of Pediatric Hematology (JSPH) sent questionnaires to hospitals with JPSH members asking for details of cases in which HLH occurred after HSCT between 1998 and 2008. RESULTS Among 42 children who were diagnosed with post-HSCT HLH between 1998 and 2008 in Japan, 37 fulfilled our inclusion criteria; of these, 26 were classified as early-onset (onset <30 days after HSCT) and 11 were classified as late-onset (onset >30 days after HSCT). In the early-onset group, the presence of respiratory symptoms, high levels of total bilirubin, and triglycerides at onset and the lack of control of GVHD with tacrolimus were significantly associated with non-resolution of HLH (P < 0.05). The survival rate was significantly higher in patients with resolution of HLH than in those without resolution (59% vs. 14%, P < 0.05). CONCLUSIONS These findings suggest that early-onset post-HSCT HLH is a specific entity of HLH, and appropriate diagnosis and prompt management need to be established.
Collapse
Affiliation(s)
- Takeshi Asano
- Department of Pediatrics, Nippon Medical School, Chiba Hokusoh Hospital, Inzai City, Chiba, Japan.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Hashii Y, Yoshida H, Kuroda S, Kusuki S, Sato E, Tokimasa S, Ohta H, Matsubara Y, Kinoshita S, Nakagawa N, Imai K, Nonoyama S, Oshima K, Ohara O, Ozono K. Hemophagocytosis after bone marrow transplantation for JAK3-deficient severe combined immunodeficiency. Pediatr Transplant 2010; 14:E105-9. [PMID: 19659508 DOI: 10.1111/j.1399-3046.2009.01217.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
HSCT is the optimal treatment for patients with SCID. In particular, HSCT from a HLA-identical donor gives rise to successful engraftment with long survival. We report a six-month-old girl with JAK3-deficient SCID who developed hemophagocytosis after BMT without conditioning from her HLA-identical father. She had suffered from pneumonia and hepatitis before BMT. Prophylaxis for GVHD was short-term methotrexate and tacrolimus. On day 18 after BMT, the patient developed hemophagocytosis in bone marrow when donor lymphocytes were increasing in peripheral blood. Analysis of chimerism confirmed host origin of macrophages and donor origin of lymphocytes. Thus, host macrophage activation was presumably induced in response to donor lymphocytes through immunoreaction to infections and/or alloantigens. HSCT for SCID necessitates caution with respect to hemophagocytosis.
Collapse
Affiliation(s)
- Yoshiko Hashii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Maakaroun NR, Moanna A, Jacob JT, Albrecht H. Viral infections associated with haemophagocytic syndrome. Rev Med Virol 2010; 20:93-105. [PMID: 20127750 PMCID: PMC7169125 DOI: 10.1002/rmv.638] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 09/18/2009] [Accepted: 10/01/2009] [Indexed: 12/12/2022]
Abstract
Haemophagocytic syndrome (HPS) or haemophagocytic lymphohistiocytosis (HLH) is a rare disease caused by a dysfunction of cytotoxic T cells and NK cells. This T cell/NK cell dysregulation causes an aberrant cytokine release, resulting in proliferation/activation of histiocytes with subsequent haemophagocytosis. Histiocytic infiltration of the reticuloendothelial system results in hepatomegaly, splenomegaly, lymphadenopathy and pancytopenia ultimately leading to multiple organ dysfunctions. Common clinical features include high fevers despite broad spectrum antimicrobials, maculopapular rash, neurological symptoms, coagulopathy and abnormal liver function tests. Haemophagocytic syndrome can be either primary, i.e. due to an underlying genetic defect or secondary, associated with malignancies, autoimmune diseases (also called macrophage activation syndrome) or infections. Infectious triggers are most commonly due to viral infections mainly of the herpes group, with EBV being the most common cause. HPS can be fatal if untreated. Early recognition of the clinical presentation and laboratory abnormalities associated with HPS and prompt initiation of treatment can be life saving. HPS triggered by viral infections generally does not respond to specific antiviral therapy but may be treated with immunosuppressive/immunomodulatory agents and, in refractory cases, with bone marrow transplantation.
Collapse
|
13
|
Takagi S, Masuoka K, Uchida N, Ishiwata K, Araoka H, Tsuji M, Yamamoto H, Kato D, Matsuhashi Y, Kusumi E, Ota Y, Seo S, Matsumura T, Matsuno N, Wake A, Miyakoshi S, Makino S, Ohashi K, Yoneyama A, Taniguchi S. High incidence of haemophagocytic syndrome following umbilical cord blood transplantation for adults. Br J Haematol 2009; 147:543-53. [PMID: 19709082 DOI: 10.1111/j.1365-2141.2009.07863.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Umbilical cord blood transplantation (CBT) is widely accepted, but one critical issue for adult patients is a low engraftment rate, of which one cause is haemophagocytic syndrome (HPS). We aimed to identify the contribution of HPS to engraftment failure after CBT, following preparative regimens containing fludarabine phosphate, in 119 patients (median age, 55 years; range; 17-69 years) with haematological diseases. Graft-versus-host disease prophylaxis comprised continuous infusion of a calcineurin inhibitor with or without mycophenolate mofetil. Of the 119 patients, 20 developed HPS within a median of 15 d (cumulative incidence; 16.8%) and 17 of them did so before engraftment. Donor-dominant chimaerism was confirmed in 16 of 18 evaluable patients with HPS. Despite aggressive interventions including corticosteroid, ciclosporin, high-dose immunoglobulin and/or etoposide, engraftment failed in 14 of 18 patients. Of these 14 patients, four received second rescue transplantation and all resulted in successful engraftment. Overall survival rates significantly differed between patients with and without HPS (15.0% vs. 35.4%; P < 0.01). Univariate and multivariate analysis identified having fewer infused CD34(+) cells as a significant risk factor for the development of HPS (P = 0.01 and 0.006, respectively). We concluded that engraftment failure closely correlated with HPS in our cohort, which negatively impacted overall survival after CBT.
Collapse
|
14
|
Hemophagocytic syndrome after hematopoietic stem cell transplantation: a prospective observational study. Int J Hematol 2009; 89:368-373. [PMID: 19252966 DOI: 10.1007/s12185-009-0261-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Revised: 01/11/2009] [Accepted: 01/22/2009] [Indexed: 10/21/2022]
Abstract
The aim of this prospective observational study was to evaluate the incidence of hemophagocytic syndrome (HPS) after hematopoietic stem cell transplantation (HSCT). Between July 2006 and December 2007, all patients who received a HSCT in our institution were included in this study. All the following criteria were needed for the diagnosis of HPS: sustained fever over 7 days; cytopenia (neutropenia and/or thrombocytopenia); presence of more than 3% mature macrophages in bone marrow; hyperferritinaemia (>1,000 ng/mL). During this study, 171 patients received a HSCT (68 allogeneic and 103 autologous). The median age was 32 years (3-62). We observed six cases of HPS (6/68; 8.8%) after allogeneic stem cell transplantation (ASCT): one case of EBV-related HPS, two cases of CMV-related HPS, and three cases with no evidence of bacterial, fungal or viral infections. We observed only one case of CMV-related HPS (1/103; 0.9%) after autologous stem cell transplantation. Four patients died despite aggressive supportive care. To our knowledge, this is the first prospective observational study conducted with the aim to evaluate the incidence of HPS after HSCT. This study provides a relatively high incidence of HPS after ASCT. When sustained fever with progressive cytopenia and hyperferritinaemia are observed, HPS should be suspected, and bone marrow aspirate considered. The rapid diagnosis of HPS and the early initiation of an appropriate treatment are essential for patient management.
Collapse
|
15
|
Okamoto M, Yamaguchi H, Isobe Y, Yokose N, Mizuki T, Tajika K, Gomi S, Hamaguchi H, Inokuchi K, Oshimi K, Dan K. Analysis of triglyceride value in the diagnosis and treatment response of secondary hemophagocytic syndrome. Intern Med 2009; 48:775-81. [PMID: 19443971 DOI: 10.2169/internalmedicine.48.1677] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND/AIMS Secondary hemophagocytic syndrome (hemophagocytic lymphohistiocytosis, HLH) follows viral infection, malignant disorders, and autoimmune disease. Criteria for HLH diagnosis, which were proposed in 2004, include hypertriglyceridemia. However, some studies reported the absence of hypertriglyceridemia in patients with secondary HLH, differing from those with primary HLH. SUBJECTS AND METHODS In this study, we investigated the presence or absence of hypertriglyceridemia in 28 patients who were diagnosed with secondary HLH between 1997 and 2007 retrospectively. There were no patients undergoing treatment for those with a history of hyperlipidemia. RESULTS The subjects consisted of 14 patients with lymphoma-associated HLH, 11 with virus-associated HLH, 2 with autoimmune disease-associated HLH, and 1 with post transplantation HLH. In 19 patients (68%), hypertriglyceridemia was noted on diagnosis or during the disease period (mean: 242 mg/dL). Furthermore, the triglyceride (TG) level decreased with the treatment-related amelioration of HLH (mean level before and after treatment: 297 and 136 mg/dL, respectively, p=0.0001). CONCLUSION These results suggest that the TG level is useful for diagnosing HLH and evaluating the treatment response. TG measurement is simple and inexpensive; therefore, this parameter can be determined several times to evaluate the treatment response.
Collapse
Affiliation(s)
- Muneo Okamoto
- Division of Hematology, Department of Internal Medicine, Nippon Medical School, Tokyo
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Koyama M, Sawada A, Yasui M, Inoue M, Kawa K. Encouraging results of low-dose etoposide in the treatment of early-onset hemophagocytic syndrome following allogeneic hematopoietic stem cell transplantation. Int J Hematol 2008; 86:466-7. [PMID: 18192120 DOI: 10.1007/bf02984009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
17
|
Tanaka H, Ohwada C, Sakaida E, Takeda Y, Abe D, Oda K, Ozawa S, Shimizu N, Masuda S, Cho R, Nishimura M, Saito Y, Nakaseko C. Successful engraftment by second cord blood transplantation with reduced-intensity conditioning after graft rejection due to hemophagocytic syndrome following initial CBT. Bone Marrow Transplant 2007; 40:995-6. [PMID: 17768388 DOI: 10.1038/sj.bmt.1705842] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
18
|
Ishida H, Yoshida H, Yoshihara T, Ito M, Morimoto A. Origin of macrophages involved in the development of allogeneic hematopoietic stem cell transplantation-associated hemophagocytic syndrome: observations on a patient with juvenile myelomonocytic leukemia. Bone Marrow Transplant 2007; 40:701-3. [PMID: 17646843 DOI: 10.1038/sj.bmt.1705783] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
19
|
Hardikar W, Pang K, Al-Hebbi H, Curtis N, Couper R. Successful treatment of cytomegalovirus-associated haemophagocytic syndrome following paediatric orthotopic liver transplantation. J Paediatr Child Health 2006; 42:389-91. [PMID: 16737484 DOI: 10.1111/j.1440-1754.2006.00879.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Haemophagocytic syndrome (HPS) following orthotopic liver transplantation is a rare event which is often fatal. We report here a case of HPS in association with cytomegalovirus (CMV) reactivation. The patient was treated with a combination of antiviral agents, immunomodulatory and supportive therapy which resulted in suppression of CMV infection and resolution of the haemophagocytosis.
Collapse
Affiliation(s)
- Winita Hardikar
- Department of Gastroenterology, University of Melbourne, Royal Children's Hospital, Melbourne, Victoria, Australia.
| | | | | | | | | |
Collapse
|
20
|
Abe Y, Choi I, Hara K, Matsushima T, Nishimura J, Inaba S, Nawata H, Muta K. Hemophagocytic syndrome: a rare complication of allogeneic nonmyeloablative hematopoietic stem cell transplantation. Bone Marrow Transplant 2002; 29:799-801. [PMID: 12040480 DOI: 10.1038/sj.bmt.1703554] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2001] [Accepted: 02/07/2002] [Indexed: 11/09/2022]
Abstract
We report two cases of patients with malignant lymphoma who presented with early onset of hemophagocytic syndrome after nonmyeloablative allogeneic peripheral blood stem cell transplantation. Fever and skin eruption developed early after transplantation, and neurological symptoms preceded cytopenia and worsened progressively. Activated macrophages with hemophagocytosis were found in bone marrow of the two patients at day 15 and 56, respectively. The fact that no obvious infectious agents associated with hemophagocytic syndrome were detected, and that serum soluble interleukin-2 receptor concentrations were elevated in the early phase after transplantation, reflecting the activation of donor-derived T cells, suggests that this complication resulted from an alloimmune response.
Collapse
Affiliation(s)
- Y Abe
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Fukuno K, Tsurumi H, Yamada T, Oyama M, Moriwaki H. Graft Failure Due to Hemophagocytic Syndrome After Autologous Peripheral Blood Stem Cell Transplantation. Int J Hematol 2001; 73:262-5. [PMID: 11372742 DOI: 10.1007/bf02981948] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hemophagocytic syndrome (HPS) after hematopoietic stem cell transplantation can occasionally cause graft failure. We describe a female patient with B-cell non-Hodgkin's lymphoma (NHL) with graft failure due to HPS 12 days after autologous peripheral blood stem cell transplantation (PBSCT). Autologous PBSCT was carried out during unconfirmed/uncertain complete remission according to the Cotswolds classification after 6 cycles of biweekly (cyclophosphamide, doxorubicin, vincristine, and prednisolone) therapy and 3 courses of salvage chemotherapy including etoposide. The patient developed a high fever on day 2 post-PBSCT. Her white blood cell count rose to 0.9 x 10(9)/L on day 10 post-PBSCT, but then began to decrease. A bone marrow aspirate on day 12 post-PBSCT revealed an increase in the number of benign histiocytes with hemophagocytosis, and the patient was diagnosed with HPS. Although high-dose methylprednisolone therapy was continued, her white blood cell count further decreased to 0.3 x 10(9)/L, and the patient died of multiple organ failure on day 29 post-PBSCT. A computed tomography scan did not identify recurrent NHL, and necropsy specimens from the bone marrow, liver, and kidney revealed no neoplastic infiltration. Bone marrow necropsy showed marked hypocellularity with active histiocytic hemophagocytosis. HPS may have been induced by infection with methicillin-resistant Staphylococcus aureus rather than by lymphoma-associated HPS.
Collapse
Affiliation(s)
- K Fukuno
- Department of Internal Medicine, Kisogawa Hospital, Aichi, Japan
| | | | | | | | | |
Collapse
|
22
|
Tiab M, Mechinaud F, Harousseau JL. Haemophagocytic syndrome associated with infections. Best Pract Res Clin Haematol 2000; 13:163-78. [PMID: 10942619 DOI: 10.1053/beha.2000.0066] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Haemophagocytic syndromes (HS) are the clinical manifestation of an increased macrophagic activity with haemophagocytosis. Pathophysiology is related to a deregulation of T-lymphocytes and excessive production of cytokines. The main clinicobiological features are fever, hepatosplenomegaly, adenopathies, skin rash, neurological features, cytopenias, hypertriglyceridaemia, hyperferritinaemia and coagulopathy. Diagnosis is based on examination of the bone marrow which shows benign histiocytes actively phagocytosing haemopoietic cells. Acquired HS are mostly associated with an underlying disease such as immunodeficiency, haematological neoplasias and autoimmune diseases. Infection-associated HS was originally described by Risdall in 1979, in viral disease. Since the initial description HS has also been documented in patients with bacterial, parasitic or fungal infections. Epstein-Barr virus (EBV) is the causative agent in most cases. In EBV-associated HS, which sometimes has a fatal course, unregulated T-cell reaction or uncontrolled B-cell proliferation may release cytokines. Management of HS consists of early diagnosis, careful screening for, and prompt treatment of, infections and detection and therapy of any underlying disease. Prognosis of infection-associated haemophagocytic syndrome (IAHS) is better than that in other types of secondary HS. Management of cytokine imbalance should be useful to improve the outcome and reduce the mortality rate in these cases.
Collapse
Affiliation(s)
- M Tiab
- Service de Médecine Interne Hématologie, Centre Hospitalier Départemental, La Roche-sur-Yon, France
| | | | | |
Collapse
|