Haemophagocytic syndrome associated with infections

Evaluation in a Cytokine Storm Model in Vivo of the Safety and Efficacy of Intravenous Administration of PRS CK STORM (Standardized Conditioned Medium Obtained by Coculture of Monocytes and Mesenchymal Stromal Cells)

Our research group has been developing a series of biological drugs produced by coculture techniques with M2-polarized macrophages with different primary tissue cells and/or mesenchymal stromal cells (MSC), generally from fat, to produce anti-inflammatory and anti-fibrotic effects, avoiding the overexpression of pro-inflammatory cytokines by the innate immune system at a given time. One of these products is the drug PRS CK STORM, a medium conditioned by allogenic M2-polarized macrophages, from coculture, with those macrophages M2 with MSC from fat, whose composition, in vitro safety, and efficacy we studied. In the present work, we publish the results obtained in terms of safety (pharmacodynamics and pharmacokinetics) and efficacy of the intravenous application of this biological drug in a murine model of cytokine storm associated with severe infectious processes, including those associated with COVID-19. The results demonstrate the safety and high efficacy of PRS CK STORM as an intravenous drug to prevent and treat the cytokine storm associated with infectious processes, including COVID-19.

Secondary Hemophagocytic Lymphohistiocytosis in a Post-COVID-19 Patient

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition caused by excessive immune system activation. HLH can be primary or secondary. Primary HLH is commonly seen in children with underlying genetic mutations, while secondary HLH can be seen at any age. It is usually triggered by inciting factors such as viral infections, patients with underlying rheumatological disease, or malignancies. It has very poor prognosis if left untreated, with survival of only a few months. While there have been around 100 cases of HLH reported during the acute phase of COVID-19 infection, very few post-COVID-19 HLH cases have been reported, only around 35 cases. Here we report a case of a 20-year-old Caucasian male who presented eight weeks after COVID-19 infection with extreme fatigue, fever, lab work concerning for HLH, and a high H score indicating a high probability of HLH. Early identification of HLH following COVID-19 recovery would allow for timely management of the condition.

The Perfect Cytokine Storm: Utilization of Lung Ultrasound During Urgent Surgery in an Infant With Multisystem Inflammatory Syndrome in Children and Hemophagocytic Lymphohistiocytosis

Reports of children with a temporal association to severe acute respiratory syndrome coronavirus-2 hospitalized with cardiogenic shock or Kawasaki-like disease began emerging in April 2020. In May 2020, the Centers for Disease Control and Prevention published the criteria for what came to be known as multisystem inflammatory syndrome in children, a postinfectious inflammatory immune response to coronavirus disease 2019 exposure. Hemophagocytic lymphohistiocytosis is a heterogeneous disease state associated with systemic hyperinflammation secondary to immune dysregulation. We describe the utility of perioperative lung ultrasound in an infant with both disease states.

Hemophagocytic lymphohistiocytosis, a new cause of death during 'post-acute COVID-19 syndrome?' A case report

'Post-acute coronavirus disease 2019 (COVID-19) syndrome' is a new term that was coined to describe a constellation of persistent symptoms and new complications following recovery from COVID-19 initial illness. Identifying post-COVID-19 complications is crucial for early diagnosis and subsequent initiation of therapies to ensure more favorable outcomes. Severe COVID-19-related hemophagocytic lymphohistiocytosis (HLH) has been previously described during the acute phase of the infection. It is characterized by hyperinflammation, multi-organ involvement, and hemophagocytosis. We report the case of a 69-year-old woman who presented, two weeks after recovery from COVID-19, with hyperosmolar state and high inflammatory markers. Bone marrow aspirate, flow cytometry, extensive viral panel and total body scan were performed. Review of bone marrow aspirate smear showed hemophagocytosis. Flow cytometry, viral panel, and total body scan were normal. The diagnosis of post COVID-19-related HLH was made. Unfortunately, the patient died despite adequate treatment. To our knowledge, this is the first case establishing a high probability of COVID-19-related HLH given its occurrence two weeks following a documented biological and clinical recovery. Awareness and early recognition of HLH features following COVID-19 recovery should prompt timely initiation of therapy.

Macrophage Activation in COVID-19 Patients in Intensive Care Unit

We report six cases of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, admitted to intensive care unit (ICU), for whom bone marrow aspirate revealed hemophagocytosis. We compared their clinical presentation and laboratory findings to those that can be encountered during a hemophagocytic lymphohistiocytosis. These observations might evoke a macrophage activation mechanism different from the one encountered in the hemophagocytic lymphohistiocytosis (HLH).

A retrospective analysis of 56 children with hemophagocytic lymphohistiocytosis

Aim

The aim of this study was to investigate the etiological factors, clinical features, and prognostic factors in children with hemophagocytic lymphohistiocytosis (HLH).

Methods

Fifty-six children with HLH in Wuhan Union Hospital, People’s Republic of China, were retrospectively analyzed in recent years. We reviewed the medical records of 56 HLH children hospitalized from 2000 to 2013 to identify the possible prognostic factors.

Results

In more than half of the cases (64.29%), the etiological factor was found to be infection. Clinical characteristics such as prolonged fever (100.00%), hepatosplenomegaly (95.24%), and pancytopenia (100.00%) were observed. Characteristic laboratory values presented with increased ferritin (64.29%), triglycerides (78.57%), transaminases (80.95%), bilirubin (67.54%), lactate dehydrogenase (95.23%), and decreased fibrinogen (61.90%), natrium (40.48%), and potassium (30.94%). Bone marrow aspiration showed hemophagocytosis in 48 cases (85.71%). Forty-two patients were treated according to HLH-2004 protocol. Out of the 42 patients, 19 cases acquired remission and 13 cases died. Ten cases lost follow-up. High lactate dehydrogenase (>2,000 U/L), high bilirubin (>2 mg/mL), and younger age (<2 years) at the time of diagnosis were adverse prognostic factors.

Conclusion

HLH is a life-threatening syndrome caused by complicated etiology. The level of lactate dehydrogenase and bilirubin accompanied with younger age were adverse factors.

Thrombocytopenia in Critical Care Patients

Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.

Viral etiology, clinical and laboratory features of adult hemophagocytic lymphohistiocytosis

Secondary hemophagocytic lymphohistiocytosis (SHLH) is a potentially fatal hyperinflammatory syndrome with a heterogeneous etiology and has nonspecific clinical and laboratory findings. The diagnosis and treatment of adult SHLH is challenging because the etiology of the disease is difficult to identify, and the majority of reported cases are pediatric patients. The aim of this study was to describe the etiology, clinical characteristics, and outcomes of adult SHLH. Fifty-four adult patients who fulfilled the criteria of SHLH were enrolled in the study. Viral etiology, blood biomarkers, and clinical manifestations of SHLH were analyzed in these patients. Twenty-four SHLH patients had viraemia, whereas 30 SHLH patients were secondary to other diseases. Epstein-Barr virus (EBV) was the most common virus that associated SHLH among all viruses studied. Severe SHLH patients with EBV-viraemia presented significantly high levels of ferritin, lactate dehydrogenase, aspartate transaminase (AST), and alanine transaminase (ALT). Positively relationships existed between EBV DNA titers and levels of AST and ALT (P < 0.05). The prognosis of SHLH patients with EBV viraemia was worse than that of non-EBV SHLH and non-viral SHLH. Our data reveal that EBV is the major pathogen in virus-associated SHLH, and EBV load influence disease development in SHLH patients with EBV infection that prognosis is worse than other viruses associated SHLH.

Hemophagocytic lymphohistiocytosis (HLH): A heterogeneous spectrum of cytokine-driven immune disorders

Hemophagocytic lymphohistiocytosis (HLH) comprises a group of life-threatening immune disorders classified into primary or secondary HLH. The former is caused by mutations in genes involved in granule-mediated cytotoxicity, the latter occurs in a context of infections, malignancies or autoimmune/autoinflammatory disorders. Both are characterized by systemic inflammation, severe cytokine storms and immune-mediated organ damage. Despite recent advances, the pathogenesis of HLH remains incompletely understood. Animal models resembling different subtypes of HLH are therefore of great value to study this disease and to uncover novel treatment strategies. In this review, all known animal models of HLH will be discussed, highlighting findings on cell types, cytokines and signaling pathways involved in disease pathogenesis and extrapolating therapeutic implications for the human situation.

Haemophagocytic syndrome associated with mucormycosis infection

Several clinical forms of mucormycosis are recognized. The tendency of mucoraceous zygomycetes to invade the blood vessels often produces a disseminated infection. A case of disseminate mucormycosis complicated by a haemophagocytic syndrome (HS) in a 32-year-old Caucasian male is reported in this article. Few cases of infection-associated HS (IAHS), involving infections caused by fungi, have been reported. In all the recorded cases, the fungal infection coexists with malignant lymphoma, immunodeficiency and a long-term steroid therapy for renal transplant or Crohn's disease. This is the second described case of the HS due to mucormycosis.

Mediastinal endodermal sinus tumor associated with fatal hemophagocytic syndrome

The association of endodermal sinus tumor, known also as yolk sac tumor, of the mediastinum with hemophagocytic syndrome is exceedingly rare with only a few cases on record. We report a 24-year-old male who had a large mediastinal germ cell tumor, proven to be an endodermal sinus tumor on biopsy. The patient developed pancytopenia and coagulopathy related to associated hemophagocytic syndrome, with a fatal outcome. A brief review of the relevant literature is presented as well.

Reactive haemophagocytic syndrome in 58 HIV-1-infected patients: clinical features, underlying diseases and prognosis

OBJECTIVE

To describe features of reactive haemophagocytic syndrome (RHS) in HIV-1-infected adult patients. To compare characteristics of patients with malignancy-associated RHS and infection-associated RHS.

DESIGN AND SETTING

Retrospective study in three departments of Infectious Diseases/Internal Medicine at three French tertiary centres.

PATIENTS AND METHODS

Medical charts of HIV-1-infected adult patients and RHS seen between January 2006 and December 2007 were reviewed. Demographic, clinical and laboratory data obtained at the time of RHS episode were compared between patients with malignancy-associated RHS and infection-associated RHS using non-parametric tests. The overall survival was assessed using the Kaplan-Meier method.

RESULTS

Fifty-eight HIV-1-infected patients were diagnosed with RHS [certain RHS n = 43, possible RHS n = 15, median (range) age 42 (23-85) years, men 76%]. At time of RHS, the median duration of HIV infection was 4 (0-22) years and 57% received HAART. The median CD4 lymphocyte count was 91 (2-387)/microl and 35% of patients had a plasma HIV-1 RNA less than 50 copies/ml. Underlying haemopathy/malignancy (Hodgkin lymphoma n = 10) or infection (tuberculosis n = 9, cytomegalovirus infection n = 5) were evidenced for 31 and 23 patients, respectively. Patients with haemopathy/malignancy-associated RHS presented more frequently with splenomegaly (97 vs. 70%, P < 0.01), lower aspartate aminotransferase (36 vs. 84 UI/l, P < 0.01) and lactate dehydrogenase (530 vs. 911 UI/l, P < 0.01) levels and CD8 cell count (234 vs. 588/microl, P < 0.01). Eighteen (31%) patients died. The overall survival was not statistically different between the two groups (P = 0.68).

CONCLUSION

In the HAART era, RHS is frequently associated with underlying haemopathy/malignancy, especially Hodgkin lymphoma. The prognosis remains poor but seems, however, better than in the pre-HAART era.

Microbiological findings and treatment of EBV-associated hemophagocytic lymphohistiocytosis: a case report

Epstein-Barr virus (EBV) is the major triggering factor for hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH). In patients with EBV-HLH, the EBV-infected T cells or natural killer cells are mostly mono- or oligoclonally proliferating, whereby hypercytokinemia plays a major role and causes hemophagocytosis, cellular damage, and dysfunction of various organs. This report describes the detection and treatment of EBV-associated HLH in the case of a 17-year-old male. Serum samples and skin swabs were tested for the presence of viral DNA using real-time PCR techniques. To confirm the molecular biological tests, electron microscopy was also performed. EBV DNA was detected with real-time PCR in both blood samples and skin swabs. The level of viral DNA constantly decreased during the applied therapy. The presence of the virus in the skin was confirmed by the appearance of herpes virus-like particles detected by electron microscopy in fluid taken from skin ulcerations. The results show that in terms of treatment, special therapeutic measures are required to control the cytokine storm generated by EBV and to suppress proliferating EBV genome-containing cells because the clinical course is often fulminate and results in a poor outcome. Therefore the potential of chemotherapy with a combination of steroids, etoposide, and cyclosporine to control HLH was assessed in the adolescent, who met the stringent diagnostic criteria for this reactive disorder of the mononuclear phagocyte system.

Necrotizing epiglottitis and hemophagocytic lymphohistiocytosis

With the introduction of vaccination for haemophilus influenza, the epidemiology of epiglottitis in children has changed. Classic childhood epiglottitis is now rare, and unusual forms of the disease may be seen. Nectrotizing epiglottitis is an extremely rare form of epiglottitis. Only four cases of nectrotizing epiglottitis have been previously reported, and all cases were in immunocompromised adult patients. Hemophagocytic lymphohistiocytosis is a rare condition characterized by high fevers, hepatosplenomegaly, and cytopenias caused by an abnormal proliferation and activation of macrophages. We report the first case of a previously healthy 5-year-old male presenting with acute onset of airway distress and pancytopenia. Subsequent airway evaluation led to the diagnosis of nectrotizing epiglottitis, and he was simultaneously diagnosed with infection-induced hemophagocytic lymphohistiocytosis. The patient recovered with intubation and antibiotics. Follow-up direct laryngoscopy revealed an epiglottis remnant with approximately 50% loss of epiglottic tissue. The presentation and pathophysiology of this unusual manifestation of epiglottitis and hemophagocytic lymphohistiocytosis will be reviewed. In the post-haemophilus influenze vaccination era, the pediatric otolaryngologist must be familiar with unusual forms of epiglottitis and its associated manifestations.

Enterovirus-associated hemophagocytic syndrome in children with malignancy: report of three cases and review of the literature

Enteroviruses can cause severe manifestations in children with malignancy. Infection-associated hemophagocytic syndrome (IAHS) due to enterovirus is a rare entity in children. Patients with malignancy and IAHS due to enterovirus were retrospectively evaluated at the University of Athens' Hematology-Oncology pediatric unit within a 6-year period (2000-2006). IAHS occurred in three cases among 56 patients with documented enteroviral infection. The diagnosis of IAHS was confirmed by bone marrow aspiration and biopsy. Nested reverse transcriptase-polymerase chain reaction (RT-PCR), sequencing of the amplified alleles, and immunohistochemistry were performed to document the presence of enterovirus. The type of enterovirus was specified by indirect immunofluorescence assay. At the early phase of the disease, patients presented mild, non-specific viral symptoms, persistent unexplained fever, and pancytopenia. At the late phase, patients had more severe manifestations, such as persistent high fever, diarrhea, weight loss, hepatosplenomegaly, and hepatic dysfunction. The therapeutic approach consisted of supportive care, administration of immunoglobulin (400 mg/kg or 2 g/kg), and pleconaril. All patients had fatal outcome; two patients succumbed to multiorgan failure (MOF), while one patient succumbed to ventricular fibrillation. IAHS usually has fulminant course and leads to severe and life-threatening complications, such as liver failure and MOF. IAHS should always be included in the differential diagnosis of viral syndrome or unexplained fever. The therapeutic approach for IAHS should be administered as early as possible, before the progression to irreversible tissue damage. Early therapeutic intervention involving high doses of immunoglobulin might be beneficial for the patient's outcome.

Definition, diagnosis, and management of intravascular large B-cell lymphoma: proposals and perspectives from an international consensus meeting

Intravascular large B-cell lymphoma (IVLBCL) is a rare form of diffuse LBCL characterized by preferential intravascular growth of malignant lymphocytes, aggressive behavior, and an often fatal course. IVLBCL usually affects elderly patients with poor performance status, elevated lactic dehydrogenase serum levels, anemia, and B symptoms. It displays some differences in clinical presentation among diverse geographical areas, mostly between patients diagnosed in Western countries and Japan. In addition, data from the literature suggest that pathologic diagnostic criteria as well as clinical features of this disease may be broader than described in current classification scheme(s). Under the sponsorship of the International Extranodal Lymphoma Study Group, clinicians and pathologists with interest in IVLBCL, coming from Western and Eastern countries, joined to reach a consensus on defining features as well as to focus on the most urgent unresolved issues in IVLBCL. To this end, a representative group of IVLBCL patients coming from both the aforementioned geographical areas were collectively analyzed. Additional features of IVLBCL were proposed both under clinical and pathologic stand points. At the meeting, it emerged that IVLBCL may have additional histopathologic/cytologic definition criteria with respect to those currently recommended, some clinical features are not randomly distributed worldwide, recent therapeutic approaches, such as anti-CD20-containing regimens, may improve outcome, and kidney, spleen, and liver involvement may show peculiar histopathologic features. Finally, a provisional practical diagnostic approach to hemophagocytosis-associated patients and a proposal for the most useful criteria in the settings of differential diagnosis are included.

Micrococcus sedentarius bacteraemia presenting with haemophagocytic syndrome in previously healthy boy

Haemophagocytic syndromes are the clinical manifestation of an increased macrophagic activity with haemophagocytosis. 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. We describe a case of Micrococcus sedentarius bacteraemia in a previously healthy 10-y-old boy with haemophagocytic syndrome. Species of micrococci are generally considered as non-pathogenic commensals that colonize the skin, mucosae and oropharynx. We report the first case of Microccoccus sedentarius bacteraemia in an immunocompetent host and first case of HS associated with Micrococcus species.

Infection-associated haemophagocytosis: the tropical spectrum

Reactive proliferation and inappropriate activation of mature histiocytes with haemophagocytosis (HP) may occur in association with a wide variety of infections, neoplasms, collagen vascular diseases, and acquired and inherited immunodeficiency states. The association with infections is particularly important because overwhelming HP can obscure the typical clinical features of the primary disease and negatively affects outcome. A high index of suspicion is required for early recognition of associated HP as the cause of cytopenias. Institution of specific therapy is crucial for survival. This study highlights the wide spectrum of tropical diseases that can have associated reactive HP. Thirty cases with documented prominent HP on bone marrow aspiration smears were reviewed. Twenty-one (69%) of the marrows were from patients who had common tropical infections: malaria, typhoid and visceral leishmaniasis and 11 of 15 patients (73%) who were followed up improved on specific infection-directed and supportive measures. The presence of severe HP in bone marrow smears correlated with marked cytopenias. Recognition of HP in this geographical region should stimulate the search for one of these infections as early institution of specific therapy is crucial for patient survival.

Atraumatic rupture of the spleen associated with hemophagocytic syndrome and isolated splenic peliosis. Case report

Atraumatic rupture of the spleen is an uncommon condition that may be associated with various etiologies. The hemophagocytic syndrome (HS) and isolated splenic peliosis are two rare conditions, each of which has previously been described in association with splenic rupture. We describe a unique case of atraumatic splenic rupture in which concurrent HS and splenic peliosis were diagnosed following splenectomy. Given that both these rare conditions have probably caused the splenic rupture, a possible association between these entities is discussed.

Critical care clotting catastrophies

Coagulation problems are very common in intensive care patients. It is important to recognize potential problems, perform a rapid assessment, and start therapy. The author reviews general clinical and laboratory approaches to diagnosis and treatment of the bleeding patient and to correction of coagulopathies. This review outlines a set of often catastrophic coagulation problems, which may present both thrombotic and bleeding challenges. These include heparin induced thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation.

Virus-associated hemophagocytic syndrome in an international traveler as a differential diagnosis of SARS

During the epidemic of severe acute respiratory syndrome in 2003, a 27-year- old Japanese woman presented a high fever and acute respiratory distress with pulmonary infiltrates after traveling to a high-risk area. An alternative diagnosis was made as Epstein-Barr virus-associated hemophagocytic syndrome, based on the proliferation of macrophages with hemophagocytosis in the bone marrow and Epstein-Barr viral marker profiles. Virus-associated hemophagocytic syndrome in an international traveler should be included in the differential diagnosis of severe acute respiratory syndrome.

Hodgkin's lymphoma, Epstein-Barr virus reactivation and fatal haemophagocytic syndrome

Haemophagocytic syndrome is a serious disorder, often related to Epstein-Barr virus (EBV) or other infectious agents. Frequently an underlying immune abnormality or a T-cell lymphoma is present. The combination of haemophagocytosis and Hodgkin's lymphoma seems to be rare. A 70-year-old female with rheumatoid arthritis was admitted with constitutional symptoms, persistent fever, pancytopenia, deranged liver enzymes, lymphadenopathy and splenomegaly. A fatal coagulopathy supervened. The clinical picture and the bone marrow findings indicated a haemophagocytic syndrome and a lymph node biopsy disclosed an EBV-positive Hodgkin's lymphoma. EBV serology pointed at viral reactivation and a high EBV DNA content was detected in serum by real-time quantitative PCR analysis (5.5 x 10(6) copies per mL). The case history is presented and the literature is reviewed.

Hemophagocytic syndrome in children: an important diagnostic consideration in fever of unknown origin

To study the evolution of hemophagocytic syndrome (HPS) in children, we performed a retrospective review of 19 patients (median age, 17.4 months) in whom an infectious diseases consultation was requested at Texas Children's Hospital during the period of September 1991 through September 2001. Clinical findings consistent with HPS most frequently presented during days 6-14 of illness, concomitant with laboratory abnormalities. Fever was present for a median of 19 days before the diagnosis of HPS. Elevated serum lactate dehydrogenase and ferritin levels were noted in all patients. An infectious agent was identified in 42% of patients; 16% were found to have immunologic or vasculitic disease. HPS is a rare but often fatal disease that can initially present as fever of unknown origin with varying clinical findings, and it can be recognized by physicians who are familiar with the evolution of HPS. It is likely that many of these cases remain undiagnosed because of the HPS's rapidly fatal course.

Hemophagocytic syndrome associated with multiple myeloma

Hemophagocytic syndrome (HPS) is an uncommon reactive disorder characterized by proliferation of histiocytes that actively engulf other hematopoietic cells causing cytopenia. It complicates several diseases including hematological neoplasias. We report the case of a 54-year-old woman who was admitted to our hospital with fever of unknown origin. Her clinical picture was characterized by renal failure, splenomegaly and pancytopenia. Findings on bone marrow examination showed HPS associated with multiple myeloma. A review of the literature revealed that only one case has previously been published.