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Chen L, Wang J, Wang Z. PD-1 Blockade-Induced Hemophagocytic Lymphohistiocytosis, a Dilemma Therapeutic Outcome in 2 Patients with CAEBV: A Case Series. Infect Drug Resist 2024; 17:1545-1550. [PMID: 38650754 PMCID: PMC11034567 DOI: 10.2147/idr.s441460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), whether primary or secondary, is a rare and fatal clinical syndrome of uncontrolled immune activation and inflammatory cascade. Immune checkpoint inhibitors (ICIs) induced HLH has no standard diagnostic and treatment guidelines. Early diagnosis and appropriate treatment according to different disease backgrounds are crucial. Herein, we first report 2 cases of patients with chronic active Epstein-Barr virus infection (CAEBV) who developed HLH after the use of sintilimab, a monoclonal antibody against programmed cell death protein 1 (PD-1), and the DEP (liposomal doxorubicin, etoposide, methylprednisolone) chemotherapy regimen in combination with ruxolitinib were used to successfully control the disease.
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Affiliation(s)
- LeiLei Chen
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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2
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Liu C, Gao J, Liu J. Management of hemophagocytic lymphohistiocytosis in pregnancy: Case series study and literature review. J Obstet Gynaecol Res 2022; 48:610-620. [PMID: 34978123 PMCID: PMC9303886 DOI: 10.1111/jog.15133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
Aim The diagnosis and treatment of hemophagocytic lymphohistiocytosis (HLH) in pregnancy is challenging due to its rarity. We aim to analyze and summarize the clinical characteristics of HLH in pregnancy, and to discuss effective diagnostic and treatment options. Methods Thirteen patients with HLH during pregnancy who were diagnosed and treated at the Peking Union Medical College Hospital of the Chinese Academy of Medical Sciences from January 2000 to December 2019 were studied retrospectively. We collected data on treatment regimens and on maternal and pregnancy outcomes. Results All patients had a singleton pregnancy, with a median age of 28 years (range, 22–33 years) and a median gestational age of 23 weeks (7–36 weeks). Twelve patients received corticosteroids, and four patients (with/without intravenous immunoglobulin) showed a curative effect. Two patients who were treated with dexamethasone and etoposide after termination of pregnancy achieved complete remission. Two patients attained remission after termination of pregnancy. Four pregnant women died, and the mortality rate was 30.8% (4/13). Fetal or neonatal death up to 1 week after delivery occurred in eight (61.5%) pregnancies. Conclusions Early diagnosis and treatment are important for maternal survival, and corticosteroids are the first choice for most patients with HLH during pregnancy. For patients who do not respond to corticosteroids, etoposide and termination of pregnancy may be life‐saving.
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Affiliation(s)
- Congcong Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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3
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Takahashi M, Makino S, Iizuka H, Noguchi M, Yoshida K. Chronic active Epstein-Barr virus-associated secondary hemophagocytic lymphohistiocytosis in pregnancy: a case report. BMC Pregnancy Childbirth 2021; 21:681. [PMID: 34620104 PMCID: PMC8495184 DOI: 10.1186/s12884-021-04150-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare and fatal disease characterized by uncontrolled immune cell activation that can lead to a cytokine storm. Unfortunately, this condition can occur even during pregnancy, threatening both maternal and fetal lives. CASE PRESENTATION A 23-year-old nulliparous woman at 26 weeks of gestation presented with continuous fever, coughing, and sore throat. Upon arrival at our hospital, her temperature was >38°C and laboratory findings indicated cytopenia (neutrophil count, 779/μL; hemoglobin level, 10.2 g/dL; platelet count, 29,000/μL), elevated ferritin level (1,308 ng/mL), and elevated soluble interleukin-2 receptor level (11,200 U/mL). Computed tomography showed marked splenomegaly. Bone marrow examination revealed hemophagocytosis, and blood examination showed a plasma Epstein-Barr virus (EBV) DNA level of 8.9 × 105 copies/μg. The monoclonal proliferation of EBV-infected T cells was confirmed by Southern blotting, and the patient was diagnosed with chronic active EBV-associated sHLH and T-cell lymphoproliferative disease. Immediately after admission, the patient's condition suddenly deteriorated. She developed shock and disseminated intravascular coagulation, requiring endotracheal intubation along with methylprednisolone pulse and etoposide therapy. Although the patient recovered, she delivered a stillborn baby. After delivery, she was treated with reduced-dose dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC) and steroid (dexamethasone), methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) chemotherapies. Five months after diagnosis, she received human leukocyte antigen-haploidentical allogeneic bone marrow transplantation from her sister. She remains in remission for 5 months from the time of transplantation to the present. CONCLUSIONS sHLH, which may cause maternal and fetal death, should be carefully considered in critically ill pregnant women, particularly those presenting with continuous fever and cytopenia.
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Affiliation(s)
- Masaya Takahashi
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan.
| | - Hiroko Iizuka
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Koyo Yoshida
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
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Wilson-Morkeh H, Frise C, Youngstein T. Haemophagocytic lymphohistiocytosis in pregnancy. Obstet Med 2021; 15:79-90. [DOI: 10.1177/1753495x211011913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.
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Affiliation(s)
- Harold Wilson-Morkeh
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Charlotte Frise
- Fetal-Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- De Swiet’s Obstetric Medicine Centre, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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Cytokine Storms in the Course of COVID-19 and Haemophagocytic Lymphohistiocytosis in Pregnant and Postpartum Women. Biomolecules 2021; 11:biom11081202. [PMID: 34439868 PMCID: PMC8391528 DOI: 10.3390/biom11081202] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022] Open
Abstract
The term ‘cytokine storm’ (CS) applies to a pathological autoimmune reaction when the interactions that lead to cytokine production are destabilised and may even lead to death. CS may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we present our analysis of certain pathological processes that induce a CS in pregnant and postpartum women. We draw our attention to the similarities between the severe course of Coronavirus Disease 2019 (COVID-19) and haemophagocytic lymphohistiocytosis (HLH). It is noteworthy that many of the criteria used to diagnose HLH are described as COVID-19 mortality predictors. Cytokine storms are considered to be an important cause of death in patients with the severe course of SARS-CoV-2 infection. Due to the fact that pregnant women are in an immunosuppressive state, viral pulmonary infections are more perilous for them—possible risks include miscarriage, intrauterine growth restriction or birth before the term; sometimes ventilation support is needed. HLH should be considered in pregnant and puerperal women suffering from moderately severe to severe COVID-19 and presenting with: fever unresponsive to antibiotic therapy, cytopenia, hepatitis and hyperferritinaemia. The HLH disorder is rare and difficult to diagnose; however, its early detection could reduce patient mortality.
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Grigorieva KN, Bitsadze VO, Khizroeva JK, Tretyakova MV, Blinov DV, Tsibizova VI, Ponomarev DA, Shkoda AS, Orudzhova EA, Grandone E, Rizzo G, Makatsariya AD. Macrophage activation syndrome in COVID-19. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The novel coronavirus epidemic is characterized by high rates of morbidity and relatively high mortality. Laboratory test results in patients include leukopenia, an increase in liver function tests and ferritin levels reaching hundreds, and sometimes thousands of units. These data remind us about the macrophage activation syndrome (MAC). Secondary hemophagocytic lymphohistiocytosis syndrome, MAC, which pathogenesis is based on a defect in the mechanisms of T-cell cytotoxicity and decreased level of natural killer cells associated with the defect in the perforin-encoding gene as well as hyperproduction of a number of cytokines – interleukin (IL)-1â, tumor necrosis factor-á, etc. by T-lymphocytes and histiocytes, indirectly leading to the activation of macrophages and production of proinflammatory cytokines, in particular IL-6 hyperproduction. MAC is one of "hyperferritinemic syndromes". These disorders have similar clinical and laboratory manifestations, and they also respond to similar treatments, suggesting that hyperferritinemia may be involved in the overall pathogenesis and is characterized by elevated ferritin level and cytokine storm. Despite the fact that data on the immune and inflammatory status in patients with COVID-19 have only started to appear, it is already clear that hyperinflammation and coagulopathy affect the disease severity and increase the risk of death in patients infected with SARS-CoV-2. Hence, understanding the pathogenesis of the novel coronavirus infection can help in its early diagnostics and treatment.
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Affiliation(s)
| | | | | | | | - D. V. Blinov
- Institute for Preventive and Social Medicine; Lapino Clinic Hospital, MD Medical Group
| | - V. I. Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation
| | - D. A. Ponomarev
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - A. S. Shkoda
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - E. A. Orudzhova
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - E. Grandone
- Sechenov University; Tor Vergata University of Rome
| | - G. Rizzo
- Sechenov University; Tor Vergata University of Rome
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Salama HA, Jazieh AR, Alhejazi AY, Absi A, Alshieban S, Alzahrani M, Alaskar A, Gmati G, Damlaj M, Abuelgasim KA, Alghamdi A, Alahmari B, Almugairi A, Alzahrani H, Bazarbachi A, Musa MOH, Goyal G. Highlights of the Management of Adult Histiocytic Disorders: Langerhans Cell Histiocytosis, Erdheim-Chester Disease, Rosai-Dorfman Disease, and Hemophagocytic Lymphohistiocytosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:e66-e75. [PMID: 32943371 PMCID: PMC7434330 DOI: 10.1016/j.clml.2020.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022]
Abstract
Histiocytic disorders are an exceptionally rare group of diseases with diverse manifestations and a paucity of approved treatments, thereby leading to various challenges in their diagnosis and management. With the discovery of novel molecular targets and the incorporation of targeted agents in the management of various adult histiocytic disorders, their management has become increasingly complex. In an attempt to improve the understanding of the clinical features and management of common adult histiocytic disorders (Langerhans cell histiocytosis, Erdheim-Chester disease, Rosai-Dorfman disease, and hemophagocytic lymphohistiocytosis), we created this document based on existing literature and expert opinion.
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Affiliation(s)
- Hind Abdin Salama
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia.
| | - Abdul Rahman Jazieh
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Ayman Yahya Alhejazi
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Ahmed Absi
- Section of Adult Hematology and Hematopoietic Stem Cell Transplant, Princess Nora Oncology Centre, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
| | - Saeed Alshieban
- King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia; Departments of Pathology and Clinical Laboratory, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Mohsen Alzahrani
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Ahmed Alaskar
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Giamal Gmati
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Moussab Damlaj
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Khadega A Abuelgasim
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Abdulrahman Alghamdi
- King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia; Department of Clinical Pharmacy, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Bader Alahmari
- Department of Oncology, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia
| | - Areej Almugairi
- King Saud bin Abdul-Aziz University for Health Science, College of Medicine, Riyadh, Saudi Arabia; Departments of Pathology and Clinical Laboratory, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Hazza Alzahrani
- Section of Adult Hematology and Stem Cell Transplant, Department of Oncology, King Faisal Specialist and Research Centre, Riyadh, Saudi Arabia
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine American University of Beirut, Medical Center, Beirut, Lebanon
| | - M O H Musa
- Department of Hematology, Fedail Hospital, Khartoum, Sudan
| | - Gaurav Goyal
- Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL.
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Wang S, Wu J, Jing X, Zhang Y, Tang H, Wu J. Etoposide combined with ruxolitinib for refractory hemophagocytic lymphohistiocytosis during pregnancy: a case report and literature review. ACTA ACUST UNITED AC 2020; 24:751-756. [PMID: 33138732 DOI: 10.1080/16078454.2020.1838708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune-mediated disorder caused by uncontrolled inflammatory responses and the activation of T lymphocytes. This life-threatening disease, characterized by fever, cytopenia and hepatosplenomegaly, is extremely rare during pregnancy with high mortality. Despite the improvement of treatment regimen in recent years, HLH is still a great challenge for clinicians. Here, we described a 26-year-old woman who admitted to our hospital at her first pregnancy with pyrexia. Her condition continued to deteriorate after receiving broad-spectrum antimicrobials, presenting with fever, pancytopenia, hepatosplenomegaly, ferritin ≥ 500 μg/L, hemophagocytosis and low NK-cell activity. HLH was eventually diagnosed by clinical manifestation and laboratory examination results. Then the patient recovered well after treatment with etoposide combined with ruxolitinib therapy and underwent successful induced-labor operation. Additionally, we summarized similar cases from the literature to improve the management of HLH during pregnancy. In conclusion, this study highlights the challenges and difficulties in the diagnosis and management of patients with HLH during pregnancy. Moreover, this is the first case report of etoposide combined with ruxolitinib in the treatment of patients with refractory secondary HLH during pregnancy.
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Affiliation(s)
- Shuoshan Wang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Jingguo Wu
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Xiaoli Jing
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Yongwei Zhang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Hao Tang
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Junlin Wu
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
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