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Sekimata M, Kinjo Y, Tohyama A, Murakami M, Hashiwaki S, Saito Y, Higami S, Hagimoto M, Taketomi R, Hoshino K, Harada H, Ueda T, Kurita T, Matsuura Y, Yoshino K. Cytokine release syndrome induced by immune checkpoint inhibitor treatment for uterine cervical cancer recurrence: A case report. Oncol Lett 2024; 28:331. [PMID: 38807673 PMCID: PMC11130748 DOI: 10.3892/ol.2024.14463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/09/2024] [Indexed: 05/30/2024] Open
Abstract
Cytokine release syndrome (CRS) is a systemic inflammatory condition caused by an excessive immune response and cytokine overproduction. CRS is a life-threatening condition that is often associated with chimeric antigen receptor T-cell therapy. Despite the increased use of immune checkpoint inhibitors (ICIs), ICI-induced CRS remains rare. The present study describes a case of CRS that occurred after the administration of ICIs for recurrent adenocarcinoma of the uterine cervix. A 49-year-old woman received paclitaxel, carboplatin and pembrolizumab for recurrent cervical adenocarcinoma. On day 27 of the third cycle, the patient was admitted with a fever and suspected pyelonephritis. The following day, hypotension, upper respiratory symptoms and myalgia of the extremities were noted, and the left ventricular ejection fraction (LVEF) was decreased to 20%. Multiorgan failure (MOF) occurred, and the patient received ventilator support and continuous hemodiafiltration. Rhabdomyolysis, pancreatitis, erythema multiforme and enteritis were observed. CRS was diagnosed based on elevated ferritin and IL-6 levels. Steroid pulse therapy was administered; however, the MOF did not improve and the anti-IL-6-receptor monoclonal antibody tocilizumab (TOC) was administered. Subsequently, the LVEF improved to 50%, and the patient was removed from the ventilator on day 4 and from the continuous hemodiafiltration unit on day 6 after TOC administration. The patient was discharged on day 21. In conclusion, considering that ICI-induced CRS is a rare but severe complication, fever and other systemic conditions following ICI administration should be monitored.
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Affiliation(s)
- Mao Sekimata
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Yasuyuki Kinjo
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Atsushi Tohyama
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Midori Murakami
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Sayumi Hashiwaki
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Yuma Saito
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Shota Higami
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Marina Hagimoto
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Ruka Taketomi
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Kaori Hoshino
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Hiroshi Harada
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Taeko Ueda
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Tomoko Kurita
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Yusuke Matsuura
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
- Department of Nursing of Human Broad Development, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
| | - Kiyoshi Yoshino
- Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka 807-8555, Japan
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Guo M, Zhang L, Chen K, Huang D, Feng C, Liu H, Quan N, Meng F, Deng X, Liu F. Hemophagocytic lymphohistiocytosis associated with brucellosis. Diagn Microbiol Infect Dis 2024; 109:116289. [PMID: 38663334 DOI: 10.1016/j.diagmicrobio.2024.116289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/17/2024] [Accepted: 03/25/2024] [Indexed: 05/28/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune disorder categorized as familial HLH or secondary HLH. Our case report describes a 63-year-old woman with epilepsy whose clinical signs were unremitting fever and altered consciousness. Primary abnormalities consisted of fever, splenomegaly, cytopenia, hypertriglyceridemia, hyperferritinemia and hemophagocytosis in the bone marrow. Results of blood next generation sequencing and blood culture confirmed Brucella infection. This report illustrates a sHLH case caused by Brucella melitensis infection. Here, we review the classification, clinical features, diagnostic methods, treatment regimens, differential diagnosis, and prognosis of HLH and brucellosis.
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Affiliation(s)
- Mingjing Guo
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Liqun Zhang
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Kui Chen
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Dezhi Huang
- Medical center of Hematology, Xinqiao Hospital, Key Laboratory of Trauma and Chemical Poisoning, Army Medical University, Chongqing, 400037, China
| | - Chunfeng Feng
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Hongyun Liu
- Medical center of Hematology, Xinqiao Hospital, Key Laboratory of Trauma and Chemical Poisoning, Army Medical University, Chongqing, 400037, China
| | - Nian Quan
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Fanfei Meng
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Xiaojuan Deng
- Medical center of Hematology, Xinqiao Hospital, Key Laboratory of Trauma and Chemical Poisoning, Army Medical University, Chongqing, 400037, China
| | - Fei Liu
- Department of Clinical Laboratory, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
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Yoshihara R, Tsuchiya H, Shoda H, Fujio K. Relationship between earlier introduction of tocilizumab and glucocorticoid-sparing effects on the acute phase of adult-onset Still's disease. Scand J Rheumatol 2024; 53:284-287. [PMID: 38314790 DOI: 10.1080/03009742.2024.2310358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Affiliation(s)
- R Yoshihara
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - H Tsuchiya
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - H Shoda
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - K Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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4
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Sara M, Anna S, Lorenzo B, Valentina B, Giuseppe C. Macrophage activation syndrome secondary to systemic lupus erythematosus: lesson for the clinical nephrologist. J Nephrol 2024:10.1007/s40620-024-01997-6. [PMID: 38940999 DOI: 10.1007/s40620-024-01997-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/20/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Moscardino Sara
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
| | - Sikharulidze Anna
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
| | - Beretta Lorenzo
- Referral Center for Systemic Autoimmue Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Binda Valentina
- Department of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italia.
| | - Castellano Giuseppe
- Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italia
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Tian Z, Man Q, Yang Y, Zhang X, Guan H, Gu W, Wang Y, Song D, Luo R, Wang J. Successful Treatment of Severe Steroid-Resistant Engraftment Syndrome Following Haploidentical Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia with Emapalumab: A Case Report. Cancer Manag Res 2024; 16:585-591. [PMID: 38855328 PMCID: PMC11162225 DOI: 10.2147/cmar.s458577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/12/2024] [Indexed: 06/11/2024] Open
Abstract
Engraftment syndrome (ES) is an early complication of hematopoietic stem cell transplantation (HSCT) characterized by fever and additional clinical manifestations including rash, diarrhea, lung infiltrates, weight gain, and neurological symptoms. Steroid-resistant ES following HSCT significantly affects the efficacy of transplantation and may even result in patient mortality. As ES essentially represents a cytokine storm induced by engrafted donor cells with interferon-gamma (IFN-γ) playing a central role, we hypothesized that emapalumab (an anti-IFN-γ monoclonal antibody) may be an effective approach to treat steroid-resistant ES. Here, we present a case report of a 14-year-old female patient who received a second haploidentical HSCT due to a relapse of acute myeloid leukemia. Nine days after the transplantation, the patient developed a fever and exhibited a poor response to antimicrobials (ceftazidime/avibactam). A few days later, the patient presented with a new-onset rash, weight gain, and impaired liver function, leading to a diagnosis of ES. Initial immunosuppressive (tacrolimus and mycophenolate mofetil) treatment failed to control the disease. On day 16 post-transplantation, the patient received two infusions of 50 mg of emapalumab. Following the initiation of emapalumab treatment, the patient's fever returned to normal and ES was effectively controlled. This case report demonstrated that emapalumab had a possible efficacy for steroid-resistant ES and provided a novel therapeutic strategy to treat this clinical complication.
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Affiliation(s)
- Zhengqin Tian
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
| | - Qihang Man
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
| | - Yixin Yang
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
| | - Xiaomei Zhang
- Department of Hematology, China Aerospace Science & Industry Corporation 731 Hospital, Beijing, People’s Republic of China
| | - Hexian Guan
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
| | - Wenjing Gu
- Department of Hematology, China Aerospace Science & Industry Corporation 731 Hospital, Beijing, People’s Republic of China
| | - Ying Wang
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
| | - Dandan Song
- Department of Hematology, China Aerospace Science & Industry Corporation 731 Hospital, Beijing, People’s Republic of China
| | - Rongmu Luo
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
- Department of Hematology, China Aerospace Science & Industry Corporation 731 Hospital, Beijing, People’s Republic of China
| | - Jingbo Wang
- Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China
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6
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Ruffer N, Kosch R, Weisel K, Kötter I, Krusche M. [Hemophagocytic lymphohistiocytosis and macrophage activation syndrome : A multidisciplinary challenge]. Z Rheumatol 2024; 83:376-386. [PMID: 38267764 DOI: 10.1007/s00393-023-01472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is characterized by hyperferritinemia, cytopenia, disseminated intravascular coagulopathy and functional disorders of the liver and the central nervous system. The term macrophage activation syndrome is predominantly used for secondary HLH in the context of autoimmune diseases (e.g., systemic juvenile idiopathic arthritis). In addition, malignancies and genetic inborn errors of immunity can predispose to the development of HLH. Infections (e.g., Epstein-Barr virus) in turn represent possible triggers of an acute episode. Due to the unspecific manifestation of the disease, a systematic evaluation of the organ systems is recommended in the clinical and laboratory analytical clarification of hyperinflammatory syndromes. In general, the treatment should be carried out by a multidisciplinary team with expertise in rheumatology, hematological oncology, infectious diseases and intensive care medicine. The primary treatment of HLH usually consists of glucocorticoids and in cases of a rapid deterioration of the condition anakinra (interleukin 1 block) and intravenous immunoglobulins can be employed. Treatment of the underlying disease should be consequently carried out in parallel, together with antimicrobial treatment.
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Affiliation(s)
- Nikolas Ruffer
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Ricardo Kosch
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Katja Weisel
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ina Kötter
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Nasir AZ, Khan N. Haemophagocytic lymphohistiocytosis secondary to Epstein-Barr and cytomegalovirus coinfection. BMJ Case Rep 2024; 17:e258219. [PMID: 38806401 DOI: 10.1136/bcr-2023-258219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening disorder caused by uncontrolled activation of the immune system, leading to phagocytosis of blood cells and cytokine storm. HLH can manifest in childhood due to a genetic mutation, but in adults HLH arises secondary to viral infections, autoimmune diseases or neoplastic processes. The most common viral infections associated with HLH are Epstein-Barr virus (EBV) and cytomegalovirus (CMV). EBV and CMV coinfection associated with HLH, however, is exceedingly rare. We present a case of HLH secondary to EBV and CMV coinfection in a young adult who presented with recurrent intermittent high-grade fevers and epistaxis. This case illustrates the importance of considering HLH in patients with idiopathic fevers and to consider all the potential aetiologies for HLH to ensure proper treatment.
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Affiliation(s)
- Ali Zagham Nasir
- Internal Medicine Residency, Trinity Health West Michigan Library Services, Grand Rapids, Michigan, USA
| | - Nasir Khan
- Trinity Health Grand Rapids, Grand Rapids, Michigan, USA
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Yin D, Wang J, Wang Z. The effectiveness of the doxorubicin-etoposide-methylprednisolone regimen for adult HLH secondary to rheumatic disease. Ann Hematol 2024:10.1007/s00277-024-05796-8. [PMID: 38772957 DOI: 10.1007/s00277-024-05796-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
To investigate the efficacy of the doxorubicin-etoposide-methylprednisolone, DEP) regimen as an effective treatment for adult Hemophagocytic Lymphohistiocytosis secondary to rheumatic disease and analyze prognosis in these patients. Fifty-eight adult patients diagnosed with Hemophagocytic Lymphohistiocytosis secondary to rheumatic disease admitted to Beijing Friendship Hospital from 1st Jan. 2018 to 31st Dec. 2022 were retrospectively included in this study. Patients were grouped according to previous treatment. Clinical data and laboratory characteristics of patients were retrospectively analyzed. The efficacy was evaluated every 2 weeks after initiating the first course of the DEP regimen and until the last inpatient or 31st Dec. 2023. 26 patients were included in Group A and 32 patients were included in Group B due to the previous treatment. After the first course of the DEP regimen, the overall response rate of all patients was 82.8%, with 13.8% in complete response and 69% in partial response. There was no significant statistical objective response rate between the two groups after the DEP regimen, except at 2-week. Serum ferritin, sCD25, ALT, AST, and DBIL concentrations were significantly lower at 2, 4 and 6-week than pre-treatment (P < 0.05). The overall mortality rate is 20.7% (12/58). Importantly, advanced age, initial level of HB and PLT, and central nervous system (CNS) involvement were independent poor risk factors affecting OS in bivariate analysis. The DEP regimen is effective for adult HLH secondary rheumatic disease with a high overall rate and accepted side effects.
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Affiliation(s)
- Dongfei Yin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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Chen Y, Huang X, Chen H, Tong J, Huang L, Su J, Deng L. A Case Report of Pregnancy Complicated with Primary Hemophagocytic Lymphohistiocytosis. Int J Womens Health 2024; 16:843-851. [PMID: 38774152 PMCID: PMC11107908 DOI: 10.2147/ijwh.s460352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/10/2024] [Indexed: 05/24/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome characterized by excessive activation of NK cells and cytotoxic T lymphocytes, subsequently leading to macrophage activation and increased cytokine production. Misdiagnosis due to nonspecific clinical presentations and inadequate understanding of the disease can significantly jeopardize the safety of both the mother and the infant. We report a case of pregnancy combined with HLH and conduct a literature review to provide insights into the diagnosis and treatment of pregnancy-related HLH. Case Presentation We discussed a case of a pregnant woman with persistent postpartum fever, serum ferritin, and elevated liver function, who failed to respond to repeated anti-infective therapy and was diagnosed with HLH after multidisciplinary diagnostic treatment. We gave dexamethasone treatment, and the patient's temperature and blood cells quickly returned to normal. Finally, exome sequencing revealed heterozygous variation in UNC13D gene, so we considered this case as pregnancy combined with primary HLH (pHLH). Conclusion We report the case of HLH diagnosed during pregnancy and show that early diagnosis and timely intervention can prevent rapid disease progression, reduce maternal mortality rates, and improve survival rates. Additionally, molecular genetic testing can confirm pathogenic gene mutations, providing essential genetic counseling for patients with pHLH who plan to conceive a healthy child.
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Affiliation(s)
- Yan Chen
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Xiaohuan Huang
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Hongfei Chen
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Junru Tong
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Lingling Huang
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Junyou Su
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Li Deng
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
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Correia Marques M, Ombrello MJ, Schulert GS. New discoveries in the genetics and genomics of systemic juvenile idiopathic arthritis. Expert Rev Clin Immunol 2024:1-12. [PMID: 38641907 DOI: 10.1080/1744666x.2024.2345868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/17/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Systemic juvenile idiopathic arthritis (sJIA) is a severe inflammatory condition with onset in childhood. It is sporadic, but elements of its stereotypical innate immune responses are likely genetically encoded by both common variants with small effect sizes and rare variants with larger effects. AREAS COVERED Genomic investigations have defined the unique genetic architecture of sJIA. Identification of the class II HLA locus as the strongest sJIA risk factor for the first time brought attention to T lymphocytes and adaptive immune mechanisms in sJIA. The importance of the human leukocyte antigen (HLA) locus was reinforced by recognition that HLA-DRB1*15 alleles are strongly associated with development of drug reactions and sJIA-associated lung disease (sJIA-LD). At the IL1RN locus, genetic variation relates to both risk of sJIA and may also predict non-response to anakinra. Finally, rare genetic variants may have critical roles in disease complications, such as homozygous LACC1 mutations in families with an sJIA-like illness, and hemophagocytic lymphohistiocytosis (HLH) gene variants in some children with macrophage activation syndrome (MAS). EXPERT OPINION Genetic and genomic analysis of sJIA holds great promise for both basic discovery of the course and complications of sJIA, and may help guide personalized medicine and therapeutic decision-making.
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Affiliation(s)
- Mariana Correia Marques
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Michael J Ombrello
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Dong Y, Wang T, Wu H. Heterogeneity of macrophage activation syndrome and treatment progression. Front Immunol 2024; 15:1389710. [PMID: 38736876 PMCID: PMC11082376 DOI: 10.3389/fimmu.2024.1389710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a rare complication of autoimmune inflammatory rheumatic diseases (AIIRD) characterized by a progressive and life-threatening condition with features including cytokine storm and hemophagocytosis. Predisposing factors are typically associated with microbial infections, genetic factors (distinct from typical genetically related hemophagocytic lymphohistiocytosis (HLH)), and inappropriate immune system overactivation. Clinical features include unremitting fever, generalized rash, hepatosplenomegaly, lymphadenopathy, anemia, worsening liver function, and neurological involvement. MAS can occur in various AIIRDs, including but not limited to systemic juvenile idiopathic arthritis (sJIA), adult-onset Still's disease (AOSD), systemic lupus erythematosus (SLE), Kawasaki disease (KD), juvenile dermatomyositis (JDM), rheumatoid arthritis (RA), and Sjögren's syndrome (SS), etc. Although progress has been made in understanding the pathogenesis and treatment of MAS, it is important to recognize the differences between different diseases and the various treatment options available. This article summarizes the cell types and cytokines involved in MAS-related diseases, the heterogeneity, and treatment options, while also comparing it to genetically related HLH.
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Affiliation(s)
- Yuanji Dong
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ting Wang
- Department of Respiratory Disease, Thoracic Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huaxiang Wu
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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See KC. Dengue-Associated Hemophagocytic Lymphohistiocytosis: A Narrative Review of Its Identification and Treatment. Pathogens 2024; 13:332. [PMID: 38668287 PMCID: PMC11053942 DOI: 10.3390/pathogens13040332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024] Open
Abstract
Dengue's lack of specific treatments beyond supportive care prompts a focus on uncovering additional pathophysiological factors. Dengue-associated hemophagocytic lymphohistiocytosis (HLH), characterized by dysregulated macrophage activation and cytokine storm, remains underexplored despite its potential to worsen disease severity and mortality. While rare, dengue-associated HLH disproportionately affects severe cases, significantly impacting mortality rates. To mitigate high mortality, early identification and familiarity with dengue-associated HLH are imperative for prompt treatment by clinicians. This narrative review therefore aims to examine the current clinical and therapeutic knowledge on dengue-associated HLH, and act as a resource for clinicians to improve their management of HLH associated with severe dengue. Dengue-associated HLH should be considered for all cases of severe dengue and may be suspected based on the presence of prolonged or recurrent fever for >7 days, or anemia without intravascular hemolysis or massive bleeding. Diagnosis relies on fulfilling at least five of the eight HLH-2004 criteria. Treatment predominantly involves short courses (3-4 days) of high-dose steroids (e.g., dexamethasone 10 mg/m2), with additional therapies considered in more severe presentations. Notably, outcomes can be favorable with steroid therapy alone.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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13
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Jung JI, Kim JY, Kim MH, Park JK, Lee EY, Lee EB, Park JW. Successful treatment of hemophagocytic lymphohistiocytosis in a patient with systemic lupus erythematosus with ruxolitinib: a case report. JOURNAL OF RHEUMATIC DISEASES 2024; 31:125-129. [PMID: 38559795 PMCID: PMC10973350 DOI: 10.4078/jrd.2023.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 04/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hematological disorder characterized by uncontrolled activation of CD8+ T and natural killer cells, leading to a cytokine storm and severe organ dysfunction. Although secondary HLH related to autoimmune diseases usually demonstrates a good treatment response to immunosuppressive therapy for underlying conditions, there is no consensus regarding the treatment in case of unresponsiveness to the treatment. Herein, we present a case of HLH that was unresponsive to high-dose glucocorticoid and cyclosporine treatment in a patient with newly diagnosed systemic lupus erythematosus. The patient's clinical features and laboratory abnormalities rapidly improved with ruxolitinib, an oral Janus kinase 1 and 2 (JAK1/2) inhibitor. This result suggests that blocking JAK-STAT pathway may be a potential treatment option in patients with refractory HLH secondary to autoimmune diseases.
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Affiliation(s)
- Ji In Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ju Yeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Mi Hyeon Kim
- Division of Rheumatology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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14
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Xu S, He K. Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians. Transpl Immunol 2024; 83:102007. [PMID: 38307154 DOI: 10.1016/j.trim.2024.102007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.
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Affiliation(s)
- Shanshan Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China.
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15
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Guo T, Liu Z, Chen Y, Cheng Y, He K, Lin X, Wang M, Sun Y. Hemophagocytic lymphohistiocytosis during treatment of intracranial multifocal germinoma: a case report and literature review. Front Oncol 2024; 14:1264926. [PMID: 38532931 PMCID: PMC10963405 DOI: 10.3389/fonc.2024.1264926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), also known as hemophagocytic syndrome (HPS), is a benign histiocytosis with hyperreactive proliferation of the mononuclear phagocyte system caused by immune function abnormalities, which often occurs under the background of genetic mutations, inflammation, infection or tumors. Because the research on malignancy-associated HLH (M-HLH) is focused on hematological malignancies, reports on HLH secondary to solid tumors are rare. In this case, we report a 14-year-old girl who developed HLH during treatment for intracranial multifocal germinoma, and the disease was controlled after hormone combined with etoposide(VP-16) and other related treatments. To our knowledge, there have been no documented cases of HLH caused by intracranial multifocal germinoma.
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Affiliation(s)
- Ting Guo
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Zichun Liu
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Yixin Chen
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yangyang Cheng
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Kaitong He
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Lin
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Mingzhu Wang
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yihua Sun
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
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16
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Holloway A, Ahmed S, Manson JJ. Does your unwell patient have haemophagocytic lymphohistiocytosis? Br J Hosp Med (Lond) 2024; 85:1-12. [PMID: 38557089 DOI: 10.12968/hmed.2023.0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Haemophagocytic lymphohistiocytosis is a severe systemic hyperinflammatory syndrome characterised by dysregulation of immune cells and excessive production of cytokines, also known as a cytokine storm. It has distinctive clinical features with fever, hyperferritinaemia and falling blood counts. In adults, this usually occurs secondary to an underlying driver or trigger including infection, malignancy or rheumatic diseases. Prompt treatment with immunomodulatory therapy, including corticosteroids and the recombinant IL-1 receptor antagonist anakinra, is recommended to switch off the cytokine storm. Etoposide-based regimens are sometimes needed, and newer therapies such as emapalumab and JAK inhibitors are increasingly being used. The incidence of haemophagocytic lymphohistiocytosis has increased significantly over the last 20 years which may partly reflect increased awareness of the condition. Although relatively rare, haemophagocytic lymphohistiocytosis can be encountered by a broad range of hospital physicians, so knowing how to diagnose and treat this condition is essential. This article reviews the pathogenesis, clinical features, causes, diagnosis and treatment of haemophagocytic lymphohistiocytosis to improve physician recognition and management of this condition to improve future patient outcomes.
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Affiliation(s)
- Amelia Holloway
- Department of Rheumatology, Kings College Hospital, London, UK
| | - Saad Ahmed
- Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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17
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Nguyen TTT, Kim YT, Jeong G, Jin M. Immunopathology of and potential therapeutics for secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome: a translational perspective. Exp Mol Med 2024; 56:559-569. [PMID: 38448692 PMCID: PMC10984945 DOI: 10.1038/s12276-024-01182-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 03/08/2024] Open
Abstract
Secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome (sHLH/MAS) is a life-threatening immune disorder triggered by rheumatic disease, infections, malignancies, or medications. Characterized by the presence of hemophagocytic macrophages and a fulminant cytokine storm, sHLH/MAS leads to hyperferritinemia and multiorgan failure and rapidly progresses to death. The high mortality rate and the lack of specific treatments necessitate the development of a new drug. However, the complex and largely unknown immunopathologic mechanisms of sHLH/MAS, which involve dysfunction of various immune cells, diverse etiologies, and different clinical contexts make this effort challenging. This review introduces the terminology, diagnosis, and clinical features of sHLH/MAS. From a translational perspective, this review focuses on the immunopathological mechanisms linked to various etiologies, emphasizing potential drug targets, including key molecules and signaling pathways. We also discuss immunomodulatory biologics, existing drugs under clinical evaluation, and novel therapies in clinical trials. This systematic review aims to provide insights and highlight opportunities for the development of novel sHLH/MAS therapeutics.
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Affiliation(s)
- Tram T T Nguyen
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Yoon Tae Kim
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Geunyeol Jeong
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Mirim Jin
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea.
- Lee Gil Ya Cancer and Diabetes Institute, Gachon University, Incheon, Republic of Korea.
- Department of Microbiology, College of Medicine, Gachon University, Incheon, Republic of Korea.
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18
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Gleeson TA, Kaiser C, Lawrence CB, Brough D, Allan SM, Green JP. The NLRP3 inflammasome is essential for IL-18 production in a murine model of macrophage activation syndrome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.27.582284. [PMID: 38464243 PMCID: PMC10925192 DOI: 10.1101/2024.02.27.582284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Hyperinflammatory disease is associated with an aberrant immune response resulting in cytokine storm. One such instance of hyperinflammatory disease is known as macrophage activation syndrome (MAS). The pathology of MAS can be characterised by significantly elevated serum levels of interleukin (IL)-18 and interferon (IFN)-γ. Given the role for IL-18 in MAS, we sought to establish the role of inflammasomes in the disease process. Using a murine model of CpG-DNA induced MAS, we discovered that the expression of the NLRP3 inflammasome was increased and correlated with IL-18 production. Inhibition of the NLRP3 inflammasome, or downstream caspase-1, prevented MAS-mediated upregulation of plasma IL-18 but interestingly did not alleviate key features of hyperinflammatory disease including hyperferritinaemia and splenomegaly. Furthermore IL-1 receptor blockade with IL-1Ra did not prevent the development of CpG-induced MAS, despite being clinically effective in the treatment of MAS. These data demonstrate that in the development of MAS, the NLRP3 inflammasome was essential for the elevation in plasma IL-18, a key cytokine in clinical cases of MAS, but was not a driving factor in the pathogenesis of CpG-induced MAS.
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Affiliation(s)
- Tara A Gleeson
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | | | - Catherine B Lawrence
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - David Brough
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Stuart M Allan
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Jack P Green
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
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19
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Jevtic D, da Silva MD, Haylock AB, Nordstrom CW, Oluic S, Pantic N, Nikolajevic M, Nikolajevic N, Kotseva M, Dumic I. Hemophagocytic Lymphohistiocytosis (HLH) in Patients with Tick-Borne Illness: A Scoping Review of 98 Cases. Infect Dis Rep 2024; 16:154-169. [PMID: 38525759 PMCID: PMC10961790 DOI: 10.3390/idr16020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) secondary to tick-borne infections is a rare but potentially life-threatening syndrome. We performed a scoping review according to PRISMA guidelines to systematically analyze the existing literature on the topic. A total of 98 patients were included, with a mean age of 43.7 years, of which 64% were men. Most cases, 31%, were reported from the USA. Immunosuppression was present in 21.4%, with the most common cause being previous solid organ transplantation. Constitutional symptoms were the most common, observed in 83.7% of the patients, while fever was reported in 70.4% of cases. Sepsis was present in 27.6%. The most common laboratory abnormalities in this cohort were thrombocytopenia in 81.6% of patients, while anemia, leukopenia, and leukocytosis were observed in 75.5%, 55.1%, and 10.2%, respectively. Liver enzyme elevation was noted in 63.3% of cases. The H-score was analyzed in 64 patients, with the mean value being 209, and bone marrow analysis was performed in 61.2% of patients. Ehrlichia spp. was the main isolated agent associated with HLH in 45.9%, followed by Rickettsia spp. in 14.3% and Anaplasma phagocytophilum in 12.2%. Notably, no patient with Powassan virus infection or Lyme borreliosis developed HLH. The most common complications were acute kidney injury (AKI) in 35.7% of patients, shock with multiple organ dysfunction in 22.5%, encephalopathy/seizure in 20.4%, respiratory failure in 16.3%, and cardiac complications in 7.1% of patients. Treatment included antibiotic therapy alone in 43.9%, while 5.1% of patients were treated with immunosuppressants alone. Treatment with both antibiotics and immunosuppressants was used in 51% of patients. Appropriate empiric antibiotics were used in 62.2%. In 43.9% of cases of HLH due to tick-borne disease, patients received only antimicrobial therapy, and 88.4% of those recovered completely without the need for immunosuppressive therapy. The mortality rate in our review was 16.3%, and patients who received inappropriate or delayed empiric therapy had a worse outcome. Hence, we suggest empiric antibiotic treatment in patients who are suspected of having HLH due to tick-borne disease or in whom diagnostic uncertainty persists due to diagnostic delay in order to minimize mortality.
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Affiliation(s)
- Dorde Jevtic
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.J.); (A.B.H.)
- Department of Medicine, NYC Health + Hospitals/Elmhurst, New York, NY 11373, USA
| | | | - Alberto Busmail Haylock
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.J.); (A.B.H.)
- Department of Medicine, NYC Health + Hospitals/Elmhurst, New York, NY 11373, USA
| | - Charles W. Nordstrom
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA;
- Mayo Clinic College of Medicine and Science, Rochester, MN 55902, USA
| | - Stevan Oluic
- Department of Internal Medicine, Mayo Clinic Health System, Mankato, MN 56001, USA;
| | - Nikola Pantic
- Clinic of Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Milan Nikolajevic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.N.); (N.N.)
| | - Nikola Nikolajevic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.N.); (N.N.)
| | - Magdalena Kotseva
- Internal Medicine Residency, Franciscan Health, Olympia Fields, Chicago, IL 60461, USA;
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA;
- Mayo Clinic College of Medicine and Science, Rochester, MN 55902, USA
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20
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Hagiwara S, Tanizaki J, Hayashi H, Komeda Y, Nishida N, Yoshida A, Yamamoto T, Matsubara T, Kudo M. Hemophagocytic lymphohistiocytosis induced by nivolumab/ipilimumab combination therapy: A case of lung adenocarcinoma that responded to early steroid pulse therapy. Cancer Rep (Hoboken) 2024; 7:e1960. [PMID: 38196303 PMCID: PMC10849979 DOI: 10.1002/cnr2.1960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors have been reported to have excellent therapeutic effects on various malignant tumors. However, immune-related adverse events can occur, targeting various organs. CASE PRESENTATION A 49-year-old male with lung carcinoma was started on carboplatin + pemetrexed + nivolumab (every 3 weeks) + ipilimumab (every 6 weeks), and nivolumab/ipilimumab was administered in the 3rd course. Subsequently, fever and fatigue developed, and grade 3 liver damage was also noted, so he was admitted to Kindai University Hospital. A bone marrow aspirate examination was performed on the third day of illness, and a definitive diagnosis of hemophagocytic lymphohistiocytosis (HLH) was made. It was determined that immediate therapeutic intervention was necessary, and pulse therapy with methylprednisolone was started on the third day of illness. After 3 days of pulse treatment, a rapid recovery of platelet values, a decrease in ferritin levels, and a decrease in lactate dehydrogenase were observed. Subjective symptoms such as fever and fatigue also quickly improved. CONCLUSION Early diagnosis and treatment for HLH resulted in a positive response. The number of HLH cases may increase in the future due to the expansion of immune checkpoint inhibitor indications.
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Affiliation(s)
- Satoru Hagiwara
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Junko Tanizaki
- Department of Medical OncologyKindai University Faculty of MedicineOsakaJapan
| | - Hidetoshi Hayashi
- Department of Medical OncologyKindai University Faculty of MedicineOsakaJapan
| | - Yoriaki Komeda
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Naoshi Nishida
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Akihiro Yoshida
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Tomoki Yamamoto
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Takuya Matsubara
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Masatoshi Kudo
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
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21
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Sola D, Smirne C, Bruggi F, Bottino Sbaratta C, Tamen Njata AC, Valente G, Pavanelli MC, Vitetta R, Bellan M, De Paoli L, Pirisi M. Unveiling the Mystery of Adult-Onset Still's Disease: A Compelling Case Report. Life (Basel) 2024; 14:195. [PMID: 38398704 PMCID: PMC10890189 DOI: 10.3390/life14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder. Diagnosis can take a long time, especially in the presence of confounding factors, and it is, to some extent, a process of exclusion. AOSD has life-threating complications ranging from asymptomatic to severe, such as macrophage activation syndrome (MAS), which is also referred to as hemophagocytic lymphohistocytosis (HLH). This condition is correlated with cytokine storm production and monocyte/macrophage overactivation and typically occurs with rash, pyrexia, pancytopenia, hepatosplenomegaly and systemic involvement. Exitus occurs in approximately 10% of cases. For the treatment of MAS-HLH, the Histiocyte Society currently suggests high-dose corticosteroids, with the possible addition of cyclosporine A, anti-interleukin (IL)-1, or IL-6 biological drugs; the inclusion of etoposide is recommended for the most severe conditions. In all cases, a multidisciplinary collaboration involving the resources and expertise of several specialists (e.g., rheumatologist, infectiologist, critical care medicine specialist) is advised. Herein, we provide a detailed description of the clinical case of a previously healthy young woman in which MAS developed as a dramatic onset manifestation of AOSD and whose diagnosis posed a real clinical challenge; the condition was finally resolved by applying the HLH-94 protocol (i.e., etoposide in combination with dexamethasone).
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Affiliation(s)
- Daniele Sola
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | - Carlo Smirne
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Francesco Bruggi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Chiara Bottino Sbaratta
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Aubin Cardin Tamen Njata
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Guido Valente
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Pathology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | | | - Rosetta Vitetta
- Rheumatology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | | | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
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22
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Essouma M. Autoimmune inflammatory myopathy biomarkers. Clin Chim Acta 2024; 553:117742. [PMID: 38176522 DOI: 10.1016/j.cca.2023.117742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024]
Abstract
The autoimmune inflammatory myopathy disease spectrum, commonly known as myositis, is a group of systemic diseases that mainly affect the muscles, skin and lungs. Biomarker assessment helps in understanding disease mechanisms, allowing for the implementation of precise strategies in the classification, diagnosis, and management of these diseases. This review examines the pathogenic mechanisms and highlights current data on blood and tissue biomarkers of autoimmune inflammatory myopathies.
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Affiliation(s)
- Mickael Essouma
- Network of Immunity in Infections, Malignancy and Autoimmunity, Universal Scientific Education and Research Network, Cameroon
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23
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Hirsch W, Megna B, Adeyi O, Lim N. Macrophage activation syndrome with acute hepatitis in a patient with adult-onset immunodeficiency with anti-interferon gamma antibodies: a case report. J Med Case Rep 2024; 18:6. [PMID: 38178160 PMCID: PMC10768153 DOI: 10.1186/s13256-023-04245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/05/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Macrophage activation syndrome is a rare disorder leading to unregulated immune activity manifesting with nonspecific constitutional symptoms, laboratory abnormalities, and multiorgan involvement. We report the case of a patient who presented with acute hepatitis secondary to macrophage activation syndrome diagnosed by liver biopsy and successfully treated with intravenous immune globulin, anakinra, and rituximab. CASE PRESENTATION A 42-year-old Laotian woman with adult-onset immunodeficiency with anti-interferon gamma antibodies presented with a fever, headache, generalized myalgia, dark urine, and reduced appetite in the setting of family members at home with similar symptoms. Her laboratory workup was notable for evidence of acute hepatitis without acute liver failure. After an unrevealing comprehensive infectious and noninvasive rheumatologic workup was completed, a liver biopsy was performed ultimately revealing the diagnosis of macrophage activation syndrome. She was successfully treated with intravenous immune globulin, anakinra, and rituximab. CONCLUSION This case highlights the importance of maintaining macrophage activation syndrome on the differential of a patient with acute hepatitis of unknown etiology in the correct clinical context and the value of a liver biopsy in making a diagnosis when noninvasive testing is unrevealing.
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Affiliation(s)
- William Hirsch
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Bryant Megna
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Oyedele Adeyi
- Department of Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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24
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Ebrahimi N, Noor SM, Kordasti S, Akhtari M, Norouzi S, Vakhshoori M, Abdipour A. Marginal Zone Lymphoma Manifesting as Macrophage Activation Syndrome: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241244732. [PMID: 38577998 PMCID: PMC10998482 DOI: 10.1177/23247096241244732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/02/2024] [Accepted: 03/16/2024] [Indexed: 04/06/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a form of secondary hemophagocytic lymphohistiocytosis (HLH) when it occurs in the context of rheumatologic disorders. HLH is a rare and potentially life-threatening syndrome characterized by excessive immune system activation. It is mainly seen in children and can be genetic based or related to infections, malignancies, rheumatologic disorders, or immunodeficiency syndromes. MAS can present with nonspecific symptoms, leading to a delay in diagnosis. This report describes a case of a 64-year-old female with marginal zone lymphoma and systemic lupus erythematosus who presented with a purpuric rash and acute kidney injury. She underwent a kidney biopsy and was diagnosed with MAS. This case highlights the importance of promptly recognizing MAS's symptoms and signs, allowing timely diagnosis and early therapeutic intervention. This potentially fatal condition tends to respond well to rapid treatment initiation with corticosteroids and to address the underlying condition.
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Affiliation(s)
| | | | - Shahram Kordasti
- King’s College London, UK
- Guy’s Hospital, London, UK
- Università Politecnica delle Marche, Ancona, Italy
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25
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Cox MF, Mackenzie S, Low R, Brown M, Sanchez E, Carr A, Carpenter B, Bishton M, Duncombe A, Akpabio A, Kulasekararaj A, Sin FE, Jones A, Kavirayani A, Sen ES, Quick V, Dulay GS, Clark S, Bauchmuller K, Tattersall RS, Manson JJ. Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline. THE LANCET. RHEUMATOLOGY 2024; 6:e51-e62. [PMID: 38258680 DOI: 10.1016/s2665-9913(23)00273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 01/24/2024]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by persistently activated cytotoxic lymphocytes and macrophages, which, if untreated, leads to multiorgan dysfunction and death. HLH should be considered in any acutely unwell patient not responding to treatment as expected, with prompt assessment to look for what we term the three Fs-fever, falling blood counts, and raised ferritin. Worldwide, awareness of HLH and access to expert management remain inequitable. Terminology is not standardised, classification criteria are validated in specific patient groups only, and some guidelines rely on specialised and somewhat inaccessible tests. The consensus guideline described in this Health Policy was produced by a self-nominated working group from the UK network Hyperinflammation and HLH Across Speciality Collaboration (HiHASC), a multidisciplinary group of clinicians experienced in managing people with HLH. Combining literature review and experience gained from looking after patients with HLH, it provides a practical, structured approach for all health-care teams managing adult (>16 years) patients with possible HLH. The focus is on early recognition and diagnosis of HLH and parallel identification of the underlying cause. To ensure wide applicability, the use of inexpensive, readily available tests is prioritised, but the role of specialist investigations and their interpretation is also addressed.
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Affiliation(s)
- Miriam F Cox
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Strachan Mackenzie
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ryan Low
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael Brown
- Division of Infection, University College London Hospitals NHS Foundation Trust, London, UK
| | - Emilie Sanchez
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling Carr
- Centre for Neuromuscular Diseases, National hospital of Neurology and Neurosurgery, London, UK
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Bishton
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - Akpabio Akpabio
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - Fang En Sin
- Department of Rheumatology, North Bristol NHS Trust, UK
| | - Alexis Jones
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Akhila Kavirayani
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vanessa Quick
- Department of Rheumatology, Bedfordshire Hospitals NHS Trust, Luton, UK
| | - Gurdeep S Dulay
- Department of Rheumatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Clark
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.
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26
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Dubinsky SDJ, Watt KM, Imburgia CE, Mcknite AM, Hunt JP, Rice C, Rower JE, Edginton AN. Anakinra Removal by Continuous Renal Replacement Therapy: An Ex Vivo Analysis. Crit Care Explor 2023; 5:e1010. [PMID: 38107537 PMCID: PMC10723863 DOI: 10.1097/cce.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES Patients with sepsis are at significant risk for multiple organ dysfunction, including the lungs and kidneys. To manage the morbidity associated with kidney impairment, continuous renal replacement therapy (CRRT) may be required. The extent of anakinra pharmacokinetics in CRRT remains unknown. The objectives of this study were to investigate the anakinra-circuit interaction and quantify the rate of removal from plasma. DESIGN The anakinra-circuit interaction was evaluated using a closed-loop ex vivo CRRT circuit. CRRT was performed in three phases based on the method of solute removal: 1) hemofiltration, 2) hemodialysis, and 3) hemodiafiltration. Standard control samples of anakinra were included to assess drug degradation. SETTING University research laboratory. PATIENTS None. INTERVENTIONS Anakinra was administered to the CRRT circuit and serial prefilter blood samples were collected along with time-matched control and hemofiltrate samples. Each circuit was run in triplicate to assess inter-run variability. Concentrations of anakinra in each reference fluid were measured by enzyme-linked immunosorbent assay. Transmembrane filter clearance was estimated by the product of the sieving coefficient/dialysate saturation constant and circuit flow rates. MEASUREMENTS AND MAIN RESULTS Removal of anakinra from plasma occurred within minutes for each CRRT modality. Average drug remaining (%) in plasma following anakinra administration was lowest with hemodiafiltration (34.9%). The average sieving coefficient was 0.34, 0.37, and 0.41 for hemodiafiltration, hemofiltration, and hemodialysis, respectively. Transmembrane clearance was fairly consistent across each modality with the highest during hemodialysis (5.53 mL/min), followed by hemodiafiltration (4.99 mL/min), and hemofiltration (3.94 mL/min). Percent drug remaining within the control samples (93.1%) remained consistent across each experiment, indicating negligible degradation within the blood. CONCLUSIONS The results of this analysis are the first to demonstrate that large molecule therapeutic proteins such as anakinra, are removed from plasma with modern CRRT technology. Current dosing recommendations for patients with severe renal impairment may result in subtherapeutic anakinra concentrations in those receiving CRRT.
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Affiliation(s)
- Samuel D J Dubinsky
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
| | - Kevin M Watt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - Carina E Imburgia
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Autumn M Mcknite
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - J Porter Hunt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Cassandra Rice
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Andrea N Edginton
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
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27
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Hiyama T, Kurasawa K, Hasegawa A, Miyao T, Tanaka A, Arai S, Arima M, Maezawa R. Differences and similarities in cytokine profiles of macrophage activation syndrome in systemic lupus erythematosus and adult-onset Still's disease. Clin Exp Med 2023; 23:3407-3416. [PMID: 36611087 DOI: 10.1007/s10238-023-00988-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
To clarify the differences and similarities in the cytokine profiles of macrophage activating syndrome (MAS) between systemic lupus erythematosus (SLE) and adult-onset Still's disease (AOSD). The study participants included 9 patients with MAS-SLE, 22 with non-MAS-SLE, 9 with MAS-AOSD, and 13 with non-MAS-AOSD. Serum cytokine levels were measured using a multiplex bead assay. Cytokine levels were compared between patients with SLE and AOSD with/without MAS. Moreover, cytokine patterns were examined using principal component analysis (PCA) and cluster analysis. IL-6, IL-8, IL-18, and TNF-α levels were elevated in patients with SLE and AOSD. IFN-α levels were elevated in SLE, whereas IL-1β and IL-18 levels were elevated in AOSD. In SLE, IFN-α and IL-10 levels were higher in MAS than in non-MAS and controls. PCA revealed distinctive cytokine patterns in SLE and AOSD, SLE with IFN-α and IP-10, AOSD with IL-1β, IL-6, and IL-18, and enhanced cytokine production in MAS. PCA and cluster analysis showed no differences in cytokine patterns between the MAS and non-MAS groups. However, serum ferritin levels were correlated with IFN-α levels in SLE. Cytokine profiles differed between SLE and AOSD but not between MAS and non-MAS. MAS is induced by the enhancement of underlying cytokine abnormalities rather than by MAS-specific cytokine profiles. Type I IFN may be involved in MAS development in patients with SLE.
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Affiliation(s)
- Tomoka Hiyama
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan.
| | - Anna Hasegawa
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Tomoyuki Miyao
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Ayae Tanaka
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Satoko Arai
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Masafumi Arima
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Reika Maezawa
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
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28
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Triggianese P, Vitale A, Lopalco G, Mayrink Giardini HA, Ciccia F, Al-Maghlouth I, Ruscitti P, Sfikakis PP, Iannone F, de Brito Antonelli IP, Patrone M, Asfina KN, Di Cola I, Laskari K, Gaggiano C, Tufan A, Sfriso P, Dagna L, Giacomelli R, Hinojosa-Azaola A, Ragab G, Fotis L, Direskeneli H, Spedicato V, Dagostin MA, Iacono D, Ali HH, Cipriani P, Sota J, Kardas RC, Bindoli S, Campochiaro C, Navarini L, Gentileschi S, Martín-Nares E, Torres-Ruiz J, Saad MA, Kourtesi K, Alibaz-Oner F, Sevik G, Iagnocco A, Makowska J, Govoni M, Monti S, Maggio MC, La Torre F, Del Giudice E, Hernández-Rodríguez J, Bartoloni E, Emmi G, Chimenti MS, Maier A, Simonini G, Conti G, Olivieri AN, Tarsia M, De Paulis A, Lo Gullo A, Więsik-Szewczyk E, Viapiana O, Ogunjimi B, Tharwat S, Erten S, Nuzzolese R, Karamanakos A, Frassi M, Conforti A, Caggiano V, Marino A, Sebastiani GD, Gidaro A, Tombetti E, Carubbi F, Rubegni G, Cartocci A, Balistreri A, Fabiani C, Frediani B, Cantarini L. Clinical and laboratory features associated with macrophage activation syndrome in Still's disease: data from the international AIDA Network Still's Disease Registry. Intern Emerg Med 2023; 18:2231-2243. [PMID: 37828268 PMCID: PMC10635948 DOI: 10.1007/s11739-023-03408-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/23/2023] [Indexed: 10/14/2023]
Abstract
To characterize clinical and laboratory signs of patients with Still's disease experiencing macrophage activation syndrome (MAS) and identify factors associated with MAS development. Patients with Still's disease classified according to internationally accepted criteria were enrolled in the AutoInflammatory Disease Alliance (AIDA) Still's Disease Registry. Clinical and laboratory features observed during the inflammatory attack complicated by MAS were included in univariate and multivariate logistic regression analysis to identify factors associated to MAS development. A total of 414 patients with Still's disease were included; 39 (9.4%) of them developed MAS during clinical history. At univariate analyses, the following variables were significantly associated with MAS: classification of arthritis based on the number of joints involved (p = 0.003), liver involvement (p = 0.04), hepatomegaly (p = 0.02), hepatic failure (p = 0.01), axillary lymphadenopathy (p = 0.04), pneumonia (p = 0.03), acute respiratory distress syndrome (p < 0.001), platelet abnormalities (p < 0.001), high serum ferritin levels (p = 0.009), abnormal liver function tests (p = 0.009), hypoalbuminemia (p = 0.002), increased LDH (p = 0.001), and LDH serum levels (p < 0.001). At multivariate analysis, hepatomegaly (OR 8.7, 95% CI 1.9-52.6, p = 0.007) and monoarthritis (OR 15.8, 95% CI 2.9-97.1, p = 0.001), were directly associated with MAS, while the decade of life at Still's disease onset (OR 0.6, 95% CI 0.4-0.9, p = 0.045), a normal platelet count (OR 0.1, 95% CI 0.01-0.8, p = 0.034) or thrombocytosis (OR 0.01, 95% CI 0.0-0.2, p = 0.008) resulted to be protective. Clinical and laboratory factors associated with MAS development have been identified in a large cohort of patients based on real-life data.
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Affiliation(s)
- Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University of Rome Tor Vergata, Rome, Italy
| | - Antonio Vitale
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy.
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy.
- Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
| | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Francesco Ciccia
- Department of Precision Medicine, Università Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
| | - Ibrahim Al-Maghlouth
- Rheumatology Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Petros Paul Sfikakis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Martina Patrone
- Department of Precision Medicine, Università Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
| | - Kazi Nur Asfina
- College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ilenia Di Cola
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Katerina Laskari
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Carla Gaggiano
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Abdurrahman Tufan
- Division of Rheumatology, Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Giacomelli
- Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy
- Rheumatology and Clinical Immunology, Department of Medicine, School of Medicine, University of Rome "Campus Biomedico", Rome, Italy
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gaafar Ragab
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University, 6th of October City, Egypt
| | - Lampros Fotis
- Third Department of Paediatrics, National and Kapodistrian University of Athens, General University Hospital "Attikon", Athens, Greece
| | - Haner Direskeneli
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Veronica Spedicato
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marilia Ambiel Dagostin
- Rheumatology Division, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Daniela Iacono
- Department of Precision Medicine, Università Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
| | - Hebatallah Hamed Ali
- College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Paola Cipriani
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Jurgen Sota
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Riza Can Kardas
- Division of Rheumatology, Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Navarini
- Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128, Rome, Italy
- Rheumatology and Clinical Immunology, Department of Medicine, School of Medicine, University of Rome "Campus Biomedico", Rome, Italy
| | - Stefano Gentileschi
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jiram Torres-Ruiz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Moustafa Ali Saad
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Katerina Kourtesi
- Third Department of Paediatrics, National and Kapodistrian University of Athens, General University Hospital "Attikon", Athens, Greece
| | - Fatma Alibaz-Oner
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Gizem Sevik
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Annamaria Iagnocco
- Academic Rheumatology Center, Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Turin, Italy
| | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, Lodz, Poland
| | - Marcello Govoni
- Rheumatology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S. Anna-Ferrara, University of Ferrara, Ferrara, Italy
| | - Sara Monti
- Rheumatology Department, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Fondazione, University of Pavia, Pavia, Italy
| | - Maria Cristina Maggio
- University Department Pro.Sa.M.I. "G. D'Alessandro", University of Palermo, Palermo, Italy
| | | | - Emanuela Del Giudice
- Pediatric and Neonatology Unit, Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Polo Pontino, Latina, Italy
| | - José Hernández-Rodríguez
- Vasculitis Research Unit and Autoinflammatory Diseases Clinical Unit, Department of Autoimmune Diseases, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Barcelona, Spain
| | - Elena Bartoloni
- Department of Medicine and Surgery, MED/16- Rheumatology, Università degli Studi di Perugia, P.Zza Università, 06123, Perugia, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Australia
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Armin Maier
- Rheumatology Unit, Department of Medicine, Central Hospital of Bolzano, Bolzano, Italy
| | - Gabriele Simonini
- NEUROFARBA Department, Rheumatology Unit, Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU Policlinic G Martino, Messina, Italy
| | - Alma Nunzia Olivieri
- Department of Woman, Child and of General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Tarsia
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Amato De Paulis
- Section of Clinical Immunology, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), World Allergy Organisation Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Alberto Lo Gullo
- Unit of Rheumatology, Department of Medicine, ARNAS Garibaldi Hospital, Catania, Italy
| | - Ewa Więsik-Szewczyk
- Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine, National Research Institute, Warsaw, Poland
| | - Ombretta Viapiana
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Benson Ogunjimi
- Antwerp Unit for Data Analysis and Computation in Immunology and Sequencing, University of Antwerp, Antwerp, Belgium
- Antwerp Center for Translational Immunology and Virology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
- Center for Health Economics Research and Modeling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Samar Tharwat
- Rheumatology and Immunology Unit, Internal Medicine Department, Mansoura University, Mansoura, Egypt
- Department of Internal Medicine, Faculty of Medicine, Horus University, New Damietta, Egypt
| | - Sukran Erten
- Department of Rheumatology, Faculty of Medicine Ankara City Hospital, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Rossana Nuzzolese
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Anastasios Karamanakos
- Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Mikras Asias Street 75 Goudi, 11527, Athens, Greece
| | - Micol Frassi
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Brescia, Italy
| | - Alessandro Conforti
- U.O. Medicina Generale, Ospedale San Paolo di Civitavecchia, ASL Roma 4, Civitavecchia, Rome, Italy
| | - Valeria Caggiano
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Achille Marino
- Unit of Pediatric Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy
| | | | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Enrico Tombetti
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Francesco Carubbi
- Department of Life, Health & Environmental Sciences and Internal Medicine and Nephrology Unit, Department of Medicine, University of L'Aquila and ASL Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, L'Aquila, Italy
| | - Giovanni Rubegni
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena and Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy
| | - Alessandra Cartocci
- Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alberto Balistreri
- Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena and Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy
| | - Bruno Frediani
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
- UOC Reumatologia, Azienda Ospedaliero-Universitaria Senese, ERN-RITA Center, Siena, Italy
- Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
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Wise L, Zell M. Adult-onset Still's disease complicated by macrophage activation syndrome during pregnancy: a case-based review. Clin Rheumatol 2023; 42:3159-3166. [PMID: 37322269 PMCID: PMC10587217 DOI: 10.1007/s10067-023-06664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023]
Abstract
Adult-onset Still's disease is a rare, systemic inflammatory rheumatic disease characterized by recurrent fevers, arthritis, and an evanescent rash. One of the most serious hematologic derangements that can be seen with adult-onset Still's disease is macrophage activation syndrome. Macrophage activation syndrome is characterized by activation of lymphocytes, resulting in a cytokine storm and hemophagocytosis in the bone marrow, along with multi-organ failure. Adult-onset Still's disease with macrophage activation syndrome first presenting during pregnancy is exceptionally rare; here, we report two unique cases of such a presentation and review the pertinent literature. Both of our cases presented critically ill with end-organ failure, and responded to immunosuppression; fetal demise was present in one and an emergency caesarean section with a viable fetus was performed in the other patient. Maternal outcomes were favorable in both cases and both patients did well long-term with systemic therapy. Systemic immunosuppression, particularly anti-IL1 therapy, may be considered as treatment for this rare and life-threatening condition when presenting during pregnancy.
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Affiliation(s)
- Leanna Wise
- Division of Rheumatology, Department of Internal Medicine, Keck School of Medicine, University of Southern California, 2020 Zonal Ave. IRD 431, CA 90033 Los Angeles, USA
| | - Monica Zell
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
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30
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Hajji M, Barbouch S, Kaaroud H, Ben Abdelghani K, Ben Hamida F, Harzallah A, Abderrahim E. Uncovering the Spectrum of Hemophagocytic Lymphohistiocytosis: A Nephrology Department's Analysis of 14 Cases. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231210137. [PMID: 37920369 PMCID: PMC10619340 DOI: 10.1177/11795476231210137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/10/2023] [Indexed: 11/04/2023]
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a disease of multi-organ dysfunction due to excessive immune activation causing widespread inflammation and tissue destruction. It is a severe condition associated with high morbidity and mortality. Early identification is crucial for prompt treatment. The objective of this case series is to underscore the intricacy of managing HLH in individuals with renal dysfunction. Methods This is a retrospective study of patients diagnosed with HLH in a nephrology department over a period of 30 years. We retrospectively reviewed the medical files by applying the Revised HLH-2004 criteria. Results Among the 14 female patients included, the mean age was 45.2 years (range 23-78). Nine patients presented with sudden onset of fever and chills. Physical examination revealed purpura in 3 cases, hepatomegaly and splenomegaly in 6 and 5 cases respectively, and peripheral lymphadenopathy in 1 case. Hemorrhagic complications were observed in 5 cases, hypertriglyceridemia in 9 cases, and hyperferritinemia in all cases. Hypothyroidism was observed in all cases, and impaired renal function was detected in 11 of them, with 5 experiencing it as a result of lupus nephritis, and 1 case attributed to pre-eclampsia. Hemophagocytosis was confirmed through sternal puncture in 11 cases. Treatment involved etiological therapy with corticosteroids and immunosuppressants and/or anti-infectives. Intravenous immunoglobulins were administered in 6 cases, while 2 cases required coagulation factor transfusions. Unfortunately, 9 patients did not survive. Conclusion The study highlights the need for increased awareness and prompt recognition of HLH, particularly in patients with associated renal complications.
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Affiliation(s)
- Meriam Hajji
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Samia Barbouch
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Hayet Kaaroud
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Khaoula Ben Abdelghani
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Amel Harzallah
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Ezzeddine Abderrahim
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
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31
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Yang C, Nguyen J, Yen Y. Complete spectrum of adverse events associated with chimeric antigen receptor (CAR)-T cell therapies. J Biomed Sci 2023; 30:89. [PMID: 37864230 PMCID: PMC10590030 DOI: 10.1186/s12929-023-00982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapies have been approved by FDA to treat relapsed or refractory hematological malignancies. However, the adverse effects of CAR-T cell therapies are complex and can be challenging to diagnose and treat. In this review, we summarize the major adverse events, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and CAR T-cell associated HLH (carHLH), and discuss their pathophysiology, symptoms, grading, and diagnosis systems, as well as management. In a future outlook, we also provide an overview of measures and modifications to CAR-T cells that are currently being explored to limit toxicity.
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Affiliation(s)
- Chieh Yang
- Department of Internal Medicine, School of Medicine, University of California Riverside, Riverside, CA USA
| | - John Nguyen
- Covina Discovery Center, Theragent Inc., Covina, CA USA
| | - Yun Yen
- College of Medical Technology, Taipei Medical University, Taipei City, Taiwan
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32
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Ichimura H, Ichikawa S, Ono K, Inokura K, Hoshi Y, Shirai T, Fukuhara N, Yokoyama H, Fujii H, Harigae H. Severe Bone Marrow Aplasia Following Macrophage Activation Syndrome in Systemic Lupus Erythematosus. TOHOKU J EXP MED 2023; 260:301-304. [PMID: 37164698 DOI: 10.1620/tjem.2023.j037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal complication of rheumatic diseases, characterized by activated macrophages with hemophagocytosis and multiple organ damage. We report a case of MAS associated with systemic lupus erythematosus that initially presented with severe liver dysfunction. Although it was improved with steroids and plasmapheresis, severe pancytopenia was subsequently experienced, and the bone marrow showed severe aplasia similar to aplastic anemia. Nevertheless, the administration of immunosuppressants resulted in the recovery of blood counts within two weeks. When severe MAS results in cytokine overproduction, bone marrow aplasia may occur, for which immunosuppressive therapy may be highly effective.
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Affiliation(s)
| | | | - Koya Ono
- Department of Hematology, Tohoku University Hospital
| | - Kyoko Inokura
- Department of Hematology, Tohoku University Hospital
| | - Yosuke Hoshi
- Department of Rheumatology, Tohoku University Hospital
| | | | | | | | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital
| | - Hideo Harigae
- Department of Hematology, Tohoku University Hospital
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33
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Gullickson M, Nichols L, Scheibe M. A Novel Therapy for a Rare Condition: Continuous Anakinra Infusion for a Patient With Macrophage Activation Syndrome. Cureus 2023; 15:e42968. [PMID: 37667692 PMCID: PMC10475328 DOI: 10.7759/cureus.42968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/06/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a type of hemophagocytic lymphohistiocytosis (HLH), which occurs due to excessive stimulation of the immune system. Common precipitants of MAS include disseminated infection or underlying rheumatologic disorders such as adult-onset Still's disease which is characterized as an inflammatory arthritis with daily fevers and a salmon-colored rash. We present a case of a patient with probable adult-onset Still's disease and subsequent disseminated cytomegalovirus (CMV) infection, who met the criteria for MAS based on the presence of a fever, cytopenia in multiple cell lines, elevated ferritin, presence of hemophagocytosis on bone marrow, low fibrinogen, and mild splenomegaly on physical exam. The patient responded to treatment with continuous anakinra infusion and ganciclovir for treatment of CMV. Though cytotoxic medications such as etoposide have traditionally been considered first-line treatment for HLH/MAS, interleukin-1 inhibitors such as anakinra are emerging as aless cytotoxic alternative.
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Affiliation(s)
| | - Laura Nichols
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
- Internal Medicine, Sanford Health, Fargo, USA
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34
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Green A, Jones H, Nero A, Ibrahim IF, Sarode R, Scheid LM, Webb CB, Adkins BD, Yates SG. A case of hyperhemolysis syndrome in sickle cell disease and concomitant COVID-19. Transfus Apher Sci 2023; 62:103712. [PMID: 37149492 PMCID: PMC10101481 DOI: 10.1016/j.transci.2023.103712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Hyperhemolysis syndrome (HHS) is an uncommon transfusion reaction described in several hematologic disorders, including sickle cell disease (SCD). HHS is characterized by a decline in hemoglobin (Hb) values below pre-transfusion levels following transfusion of red blood cells (RBCs), coupled with laboratory markers consistent with hemolysis. The proposed pathophysiologic mechanisms underlying HHS include increased phosphatidylserine expression, macrophage activation, and complement dysregulation. Many pathophysiologic mechanisms thought to contribute to HHS have been similarly described in cases of severe COVID-19. CASE REPORT A 28-year-old male with a history of HbSS presented with shortness of breath, right-sided chest pain, and a two-day history of fever. Polymerase chain reaction (PCR) detected SARS-CoV-2 infection with the omicron variant. The patient required an RBC transfusion (pre-transfusion hemoglobin [Hb]5.8 g/dL) with an immediate post-transfusion Hb of 6.3 g/dL. However, Hb rapidly declined to 1.7 g/dL, and lactate dehydrogenase (LDH) rose to 8701 u/L. The absolute reticulocyte count of 538 × 109/L correspondingly fell to 29 × 109/L. Despite additional RBC transfusions and initiation of immunosuppressive therapy, he expired on Day 9(D9). CONCLUSION Given the similarities in their proposed pathophysiology, patients with SCD and concomitant SARS-CoV-2 infection may be predisposed to developing HHS.
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Affiliation(s)
- Allen Green
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Heather Jones
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alecia Nero
- Department of Internal Medicine, Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ibrahim F Ibrahim
- Department of Internal Medicine, Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Sarode
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lisa M Scheid
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher B Webb
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian D Adkins
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sean G Yates
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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35
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Martins A, Pimenta S, Oliveira D, Martins F, Samões B, Costa L. Severe and life-threatening onset of systemic lupus erythematosus. REUMATOLOGIA CLINICA 2023; 19:402-403. [PMID: 37661117 DOI: 10.1016/j.reumae.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/12/2022] [Indexed: 09/05/2023]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of rheumatic diseases. We report a unique case of a previously healthy 20-year-old female presenting with MAS as first presentation of systemic lupus erythematosus. Remission was achieved with hydroxychloroquine, intravenous methylprednisolone pulse followed by oral prednisolone and cyclosporine. However, the management of MAS is still challenging, and the mortality rate remains high.
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Affiliation(s)
- Ana Martins
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Sofia Pimenta
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Daniela Oliveira
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Beatriz Samões
- Department of Rheumatology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Lúcia Costa
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal
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36
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Shao D, Pena O, Sekulic M, Valdez Imbert R, Vegivinti CTR, Jim B. Secondary haemophagocytic lymphohistiocytosis in a patient with new-onset systemic lupus erythematosus: the challenges of timely diagnosis and successful treatment. BMJ Case Rep 2023; 16:e252938. [PMID: 37429644 PMCID: PMC10335589 DOI: 10.1136/bcr-2022-252938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is an immune-mediated disease driven by abnormal macrophage activation and regulatory cell dysfunction. HLH can be primary due to genetic mutations or secondary due to infection, malignancy or autoimmune conditions. We describe a woman in her early 30s who developed HLH while being treated for newly diagnosed systemic lupus erythematosus (SLE) complicated by lupus nephritis as well as concomitant cytomegalovirus (CMV) reactivation from a dormant infection. The trigger for this secondary form of HLH may have been either aggressive SLE and/or CMV reactivation. Despite prompt treatment with immunosuppressive therapies for SLE consisting of high-dose corticosteroids, mycophenolate mofetil, tacrolimus, etoposide for HLH and ganciclovir for CMV infection, the patient developed multiorgan failure and passed away. We demonstrate the difficulty in identifying a specific cause for secondary HLH when multiple conditions are present (SLE and CMV) and the fact that, despite aggressive treatment for both conditions, the mortality for HLH remains high.
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Affiliation(s)
- Daming Shao
- Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Oscar Pena
- Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | | | | | - Belinda Jim
- Medicine, Jacobi Medical Center, Bronx, New York, USA
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37
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Khan I, Khan N, Wolfson N, Djebabria K, Rehman MEU, Anwer F. Safety of CAR-T Cell Therapy in Patients With Renal Failure/Acute Kidney Injury: Focused Review. Clin Hematol Int 2023:10.1007/s44228-023-00037-7. [PMID: 37010812 DOI: 10.1007/s44228-023-00037-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is novel immunotherapy targeting specifically cancerous cells, and has been shown to induce durable remissions in some refractory hematological malignancies. However, CAR T-cell therapy has adverse effects, such as cytokine release syndrome (CRS), immune effector-associated neurotoxicity syndrome (ICANS), tumor lysis syndrome (TLS), and acute kidney injury (AKI), among others. Not many studies have covered the repercussions of CAR T-cell therapy on the kidneys. In this review, we summarized the available evidence on the safety profile of CAR T-cell therapy in patients with pre-existing renal insufficiency/AKI and in those who develop AKI as a result of CAR T-cell therapy. With a 30% incidence of AKI post-CAR T-cell, various pathophysiological mechanisms, such as CRS, hemophagocytic lymphohistiocytosis (HLH), TLS, serum cytokines, and inflammatory biomarkers, have been shown to play a role. However, CRS is commonly reported as an underlying mechanism. Overall, 18% of patients in our included studies developed AKI after receiving CAR T-cell therapy, and most cases were reversible with appropriate therapy. While phase-1 clinical trials exclude patients with significant renal toxicity, two studies (Mamlouk et al. and Hunter et al.) reported successful treatment of dialysis-dependent patients with refractory diffuse large B-cell lymphoma, and demonstrated that CAR T-cell therapy and lymphodepletion (Flu/Cy) can be safely administered.
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Affiliation(s)
- Israr Khan
- Department of Internal Medicine, HMH Palisades Medical Center, 7600 River Rd, North Bergen, NJ, 07047, USA.
| | - Nida Khan
- Department of Internal Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Natalie Wolfson
- Department of Internal Medicine, Touro College of Osteopathic Medicine Harlem, OMS-III, New York, NY, USA
| | - Kawthar Djebabria
- Department of Internal Medicine, Annaba's University Hospital, Annaba, Algeria
| | | | - Faiz Anwer
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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38
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Deng R, Meng X, Wang A, Li R. Cutaneous granuloma annulare in an adult patient with macrophage activation syndrome. Clin Case Rep 2023; 11:e7181. [PMID: 37038537 PMCID: PMC10082351 DOI: 10.1002/ccr3.7181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 04/12/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a rare but life-threatening disorder that is associated with multiple organ involvement. Here, we described cutaneous granuloma annulare in MAS. This novel histological finding is a reminder to explore the underlying mechanisms of skin involvement in MAS, which may reveal its pathogenesis.
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Affiliation(s)
- Ruixin Deng
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
| | - Xingye Meng
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
| | - Aiping Wang
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
| | - Ruoyu Li
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
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39
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Leelaviwat N, Armin S, Mekraksakit P, Nugent K. Reactivation of Parvovirus B19 Infection: An Uncommon Trigger of Macrophage Activation Syndrome in Adult-Onset Still's Disease. Cureus 2023; 15:e37231. [PMID: 37162784 PMCID: PMC10164221 DOI: 10.7759/cureus.37231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/11/2023] Open
Abstract
A 40-year-old woman presented with four weeks of intermittent high-grade fever, cough, and joint pain, and two weeks of a generalized rash. She was found to have adult-onset Still's disease (AOSD) and rapidly developed macrophage activation syndrome (MAS) on the second day of admission. Among infectious etiologies, Epstein-Barr virus and members of the herpes virus family are common triggers of MAS. However, our patient was found to have reactivation/recurrence of parvovirus B19 infection as the cause; this is an uncommon trigger reported infrequently in the medical literature. Despite intensive treatment, the patient passed away.
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Affiliation(s)
- Natnicha Leelaviwat
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Sabiha Armin
- Internal Medicine, University of Texas Health Science Center at Houston, Houston, USA
| | | | - Kenneth Nugent
- Internal Medicine/Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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40
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Clinical and Laboratory Characteristics of Hemophagocytic Lymphohistiocytosis in Children With Severe Dengue During the 2019-2020 Outbreak in Southern Colombia. Pediatr Infect Dis J 2023; 42:e204-e211. [PMID: 36916863 DOI: 10.1097/inf.0000000000003887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled activation of inflammatory cells and an exaggerated release of cytokines. It can be triggered by different factors, including viruses, such as dengue. The objective of this study was to characterize the clinical and laboratory profiles of children with severe dengue and HLH, and to identify the risk factors for this clinical complication. METHODS An analytical study was conducted in children with severe dengue who were treated in an intensive care unit between January 2019 and March 2020. Clinical and laboratory factors were compared between patients with and without HLH. RESULTS HLH represented 13.4% (15/112) of children with severe dengue. Patients with HLH had a long-lasting fever (10.1 vs. 5.8 days; P = 0.012), low hemoglobin levels (7.6 vs. 10.8 g/dL; P = 0.000) and high aspartate aminotransferase values (4443 vs. 1061 U/L; P = 0.002), alanine transaminase (1433 vs. 487 U/L; P = 0.004), partial thromboplastin time (80.6 vs. 51.8 seconds; P = 0.010), prothrombin time (23.5 vs. 19.6 seconds; P = 0.024), triglycerides (333.7 vs. 223.2 mg/dL; P = 0.005), lactate dehydrogenase (4209 vs. 1947 U/L; P = 0.006), soluble CD25 (3488 vs. 1026 pg/mL; P = 0.014), and presented with higher frequency of myocarditis (66.7% vs. 38.3%; P = 0.048), hepatitis (5.3% vs. 1.3%; P = 0.014), bacterial coinfection (73.3% vs. 26.7%; P = 0.010) and fatal outcome (26% vs. 5%; P = 0.037). CONCLUSIONS HLH is a serious life-threatening clinical complication of dengue virus infection that must be considered, particularly during outbreaks.
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DOCK2 Mutation and Recurrent Hemophagocytic Lymphohistiocytosis. Life (Basel) 2023; 13:life13020434. [PMID: 36836791 PMCID: PMC9962445 DOI: 10.3390/life13020434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome resulting from uncontrolled hyper-inflammation, excessive immune system activation, and elevated levels of inflammatory cytokines. HLH can be caused by the inability to downregulate activated macrophages by natural killer (NK) and CD8 cytotoxic T cells through a process reliant on perforin and granzyme B to initiate apoptosis. Homozygous genetic mutations in this process result in primary HLH (pHLH), a disorder that can lead to multi-system organ failure and death in infancy. Heterozygous, dominant-negative, or monoallelic hypomorphic mutations in these same genes can cause a similar syndrome in the presence of an immune trigger, leading to secondary HLH (sHLH). A genetic mutation in a potential novel HLH-associated gene, dedicator of cytokinesis 2 (DOCK2), was identified in a patient with recurrent episodes of sHLH and hyperinflammation in the setting of frequent central line infections. He required baseline immune suppression for the prevention of sHLH, with increased anti-cytokine therapies and corticosteroids in response to flares and infections. Using a foamy-virus approach, the patient's DOCK2 mutation and wild-type (WT) control DOCK2 cDNA were separately transduced into a human NK-92 cell line. The NK-cell populations were stimulated with NK-sensitive K562 erythroleukemia target cells in vitro and degranulation and cytolysis were measured using CD107a expression and live/dead fixable cell dead reagent, respectively. Compared to WT, the patient's DOCK2 mutation was found to cause significantly decreased NK cell function, degranulation, and cytotoxicity. This study speaks to the importance of DOCK2 and similar genes in the pathogenesis of sHLH, with implications for its diagnosis and treatment.
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Tudesq JJ, Yakoub-Agha M, Bay JO, Courbon C, Paul F, Picard M, Pochon C, Sterin A, Vicente C, Canet E, Yakoub-Agha I, Moreau AS. [Management of cytokine release syndrome and macrophage activation syndrome following CAR-T cell therapy: Guidelines from the SFGM-TC]. Bull Cancer 2023; 110:S116-S122. [PMID: 34895696 DOI: 10.1016/j.bulcan.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/22/2022]
Abstract
The use of chimeric antigen receptor T cells (CAR-T) has increased since their approval in the treatment of several relapsed/refractory B cell malignancies. The management of their specific toxicities, such as cytokine release syndrome (CRS), tends to be better understood and well-defined. During the twelfth edition of practice harmonization workshops of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), a working group focused its work on the management of patients developing CRS following CAR-T cell therapy. A special chapter has been allocated to macrophage activation syndrome (MAS), a rare but life-threatening complication post-CAR-T. In addition to symptomatic measures and preemptive broad-spectrum antibiotics, immunomodulators such as tocilizumab and corticosteroids remain the corner stone for the treatment of CRS. Tocilizumab/corticosteroids-resistant CRS associated with haemophagocytosis markers (spleen and liver enlargement, hyperferritinaemia>10,000ng/mL, hypofibrinogenemia…) should direct the diagnosis towards an overlapping CRS/MAS. An adapted treatment will be based on high-dose IV anakinra and corticosteroids and chemotherapy with etoposide at late refractory stages. These complications and others delignate the need of close collaboration with an intensive care unit.
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Affiliation(s)
- Jean-Jacques Tudesq
- CHU Montpellier, université Montpellier, département d'hématologie clinique, Montpellier, France
| | | | - Jacques-Olivier Bay
- CHU Clermont-Ferrand, service de thérapie cellulaire et d'hématologie clinique adulte, Clermont-Ferrand, France
| | - Corinne Courbon
- Institut de cancérologie de la Loire, service d'hématologie, St Priest en Jarez, France
| | - Franciane Paul
- CHU Toulouse, service de réanimation polyvalente, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
| | - Muriel Picard
- CHU Toulouse, service de réanimation polyvalente, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
| | - Cécile Pochon
- CHRU de Nancy, université de Lorraine, service d'onco-hématologie pédiatrique, UMR 7365 CNRS-UL IMoPA, Vandœuvre-Lès-Nancy, France
| | - Arthur Sterin
- Hôpital La Timone Enfants, service hémato-immunologie pédiatrique, Marseille, France
| | - Céline Vicente
- CHU Toulouse, département d'hématologie, IUCT-oncopole, Toulouse, France
| | - Emmanuel Canet
- CHU de Nantes, université de Nantes, service de médecine intensive - réanimation, Nantes, France
| | - Ibrahim Yakoub-Agha
- CHU de Lille, université de Lille, hôpital Huriez, service des maladies du sang, LIRIC, INSERM U995, Lille, France
| | - Anne-Sophie Moreau
- CHU Lille, hôpital Salengro, service de médecine intensive réanimation, Lille, France.
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Rituximab, Intravitreal Bevacizumab and Laser Photocoagulation for Treatment of Macrophage Activation Syndrome and Retinal Vasculitis in Lupus: A Case Report. Int J Mol Sci 2023; 24:ijms24032594. [PMID: 36768956 PMCID: PMC9916420 DOI: 10.3390/ijms24032594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Systemic lupus erythematosus (SLE) most commonly manifests as mild to moderate disease with severe manifestations such as diffuse alveolar hemorrhage, central nervous system vasculitis, macrophage activation syndrome (MAS) or retinal vasculitis (RV) with visual disturbances occurring in a significantly smaller proportion of patients, most of whom have a poor outcome. Macrophage activation syndrome and RV are insufficiently early and rarely recognized presentations of lupus-consequently there are still no treatment recommendations. Here we present the course of diagnosis and treatment of a patient with an SLE flare that resulted in both life-threatening disease (MAS) and vision-threatening disease (RV). The patient was successfully treated with systemic immunosuppressives, a high dose of glucocorticoids and rituximab (RTX), in parallel with intraocular therapy, intravitreal bevacizumab (BEV) and laser photocoagulation.
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Tharwat S, Hamdy F, Abdelzaher MG, Bakr L, El Hassany A, Abdelsattar M, Eldesoky RT, Ibrahim EM. Life threatening macrophage activation syndrome as the initial presentation of systemic lupus erythematosus: A case report and review of the literature. THE EGYPTIAN RHEUMATOLOGIST 2023. [DOI: 10.1016/j.ejr.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Li S, Ying S, Bai J, Wang Y, Yang C, Sun Q, Fang H, Qiao J. Clinical characteristics and outcome of elderly onset adult-onset Still's disease: A 10-year retrospective study. J Transl Autoimmun 2023; 6:100196. [PMID: 36923474 PMCID: PMC10009280 DOI: 10.1016/j.jtauto.2023.100196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Objective Our objective was to retrospectively analyze the clinical characteristics and outcome of adult-onset Still's disease (AOSD) patients with elderly onset. Methods Retrospective data of patients diagnosed with AOSD in our institute during 2013-2021 were analyzed. The diagnoses were based on the Yamaguchi criteria for AOSD. All long-term follow-up data were collected from medical records and phone calls. Results In total, 281 AOSD patients were enrolled in this study, with the median follow-up interval of 47 months. Thirty-two (11.4%, ≥65 years) AOSD patients were classified into the elderly onset groups. Compared to the younger onset group, the percentage of patients with skin rash (p = 0.047), sore throat (p = 0.001), myalgia (p = 0.001), splenomegaly (p = 0.039), hepatosplenomegaly (p = 0.002) and the Pouchot's score (p = 0.002) were significantly lower in the elderly onset group. The death rate (p = 0.014) of elderly onset group is higher than younger onset group, and the independent risk factors of mortality in all AOSD patients were age at onset (HR: 1.115, p = 0.044), disseminated intravascular coagulation (HR: 391.576, p = 0.001) and pleuritis (HR: 23.162, p = 0.033). The probability of relapse was significantly increased in the patients with macrophage activation syndrome (MAS) compared with the patients without MAS (p < 0.001), though the different age groups of AOSD patients with MAS showed no difference in the probability of relapse (p = 0.737). Conclusion Elderly onset AOSD patients were distinguished by several distinct clinical features compared to younger onset AOSD patients. The frequency of relapse and complications were similar to that of AOSD patients with elderly or younger onset. A higher mortality rate was observed in elderly onset AOSD patients, and the mortality of AOSD patients was related to age at onset, DIC and pleuritis.
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Affiliation(s)
- Sheng Li
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Shuni Ying
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Juan Bai
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Yuqian Wang
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Changyi Yang
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Qingmiao Sun
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, China
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Chen Q, Zhang Q, Wang X. Connective tissue disease with macrophage activation syndrome: A case report. Medicine (Baltimore) 2022; 101:e32426. [PMID: 36595872 PMCID: PMC9794242 DOI: 10.1097/md.0000000000032426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE Macrophage activation syndrome (MAS), or secondary hemophagocytic lymphocytosis (sHLH), is a rare systemic inflammatory response syndrome that is fatal. Adult patients lack clear criteria for diagnosis and treatment, primarily derived from guidelines and protocols for treating family hemophagocytic lymphocytosis and systemic juvenile idiopathic arthritis (sJIA)-related MAS in children or from retrospective case reports. As a subtype of sHLH, MAS has a clinical presentation like sHLH, but treatment varies. Herein, we report the case of a 40-year-old female with MAS caused by a connective tissue disease. PATIENT CONCERNS The patient presented to the Rheumatology and Immunology Clinic with recurrent fever and rash, and MAS was confirmed after a series of examinations. The patient had no significant effect after treatment with JAK inhibitors, but after the use of the IL-6 inhibitor tocilizumab, the fever and rash were significantly reduced, and laboratory indicators returned to normal levels. DIAGNOSIS Considering the patient's condition and laboratory test results, we judged that the patient had connective tissue disease with MAS. INTERVENTIONS We gave sequential treatment of tocilizumab. OUTCOMES ALL indicators are mostly back to normal when the patient was monitored at the outpatient clinic. LESSONS MAS/HLH lacks clear criteria for diagnosis or treatment in adult patients and is extremely difficult to distinguish from bacterial sepsis or other systemic inflammatory response syndromes. Consequently, early diagnosis and treatment are indispensable for enhancing patient survival.
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Affiliation(s)
- Qu Chen
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, China
| | - Qiushuang Zhang
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, China
| | - Xuebin Wang
- Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, China
- *Correspondence: Xuebin Wang, Department of Rheumatology, Binzhou Medical University Hospital, Binzhou, Shandong Province, China (e-mail: )
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Baverez C, Grall M, Gerfaud-Valentin M, De Gail S, Belot A, Weber E, Reynaud Q, Sève P, Yvan J. Anakinra pour le traitement de la lymphohistiocytose hémophagocytaire. Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.10.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Anakinra for the Treatment of Hemophagocytic Lymphohistiocytosis: 21 Cases. J Clin Med 2022; 11:jcm11195799. [PMID: 36233667 PMCID: PMC9572845 DOI: 10.3390/jcm11195799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening cytokine storm syndrome. There are no definitive guidelines for the management of secondary HLH (sHLH). A recent report by a National Health Service (NHS) clinical panel has recommended anakinra as a treatment option. We aimed to analyse the efficacy and safety of anakinra for the treatment of all-cause sHLH. We conducted a multicentric retrospective study in two French University hospitals and included all patients who had a diagnosis of sHLH and who received anakinra. Among 21 patients (median age, 45 years), 13 were men. Anakinra was used as first-line therapy in 10 patients, and as monotherapy in 5 patients. We found that anakinra was effective in 19/21 patients (90.5%), with fever resolution in 19 patients (90.5%) within a median of 1.0 day (1, 2). At the Day 7 assessment, the mean CRP concentration decreased significantly (p < 0.001), as did the mean ferritin (p = 0.011). Anakinra was generally safe and well tolerated and was discontinued for side effects in only three patients (14.3%). Anakinra is an efficient and safe treatment to control sHLH of various causes. These data, together with the recent report of the NHS panel, call for the rapid conduct of prospective randomized clinical trials.
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He L, Yao S, Zhang R, Liu M, Hua Z, Zou H, Wang Z, Wang Y. Macrophage activation syndrome in adults: Characteristics, outcomes, and therapeutic effectiveness of etoposide-based regimen. Front Immunol 2022; 13:955523. [PMID: 36189240 PMCID: PMC9520258 DOI: 10.3389/fimmu.2022.955523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives To describe the clinical characteristics and outcomes of adult macrophage activation syndrome (MAS) patients and to provide experience for the treatment. Methods Adult patients with MAS admitted to Beijing Friendship Hospital from December 2014 to September 2021 were enrolled in this study. Clinical data of patients were collected and analyzed. Results A total of 118 adult MAS patients entered this study. MAS was the first manifestation in 43 (36.4%) patients, while 75 (63.6%) developed MAS after the diagnosis of autoimmune disease (AID) with a median diagnostic interval of 2 (0.5–359) months. Eighty-two patients were initially treated with glucocorticoid-based regimen; the overall response (OR) rate at the 2-week posttreatment was 37.8%. Forty-five patients switched to etoposide-based regimen, and the OR rate was 84.4%. Thirty-six patients were initially treated with etoposide-based regimen, and the OR rate at the 2-week posttreatment was 80.6%. Serum IL-18 (P = 0.021), IFN-γ (P = 0.013), IP-10 (P = 0.001), IL-10 (P = 0.041), IL-1RA (P < 0.001), and TNF-α (P = 0.020) levels of patients were significantly decreased in the remission phase than in the active phase. Levels of SDF-1α (P = 0.018) and IL-7 (P = 0.022) were higher in refractory patients, while the GRO-α level had a strong tendency toward statistical significance (P = 0.050). The probability of overall survival (OS) at 3, 6, and 36 months after HLH diagnosis were 89.8%, 89.0%, and 87.9%, retrospectively. The active MAS status at the 2-week post initial treatment [P = 0.009, HR = 15.281, 95% CI, (0.1.972, 118.430)] and baseline neutrophil count (Neu) <1.5 × 109/l [P = 0.017, HR = 3.678, 95% CI, (1.267, 10.672)] were negative prognostic factors. Conclusion MAS typically occurs within 2 months after the onset of autoimmune disease in adults. SDF-1α, IL-7, and GRO-α could be used to predict refractory MAS. The etoposide-based regimen is effective and tolerable for adult MAS.
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Affiliation(s)
- Lingbo He
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuyan Yao
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruoxi Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Menghan Liu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhengjie Hua
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Heshan Zou
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yini Wang,
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Wang Y, Liu S, Li L, Li L, Zhou X, Wan M, Lou P, Zhao M, Lv K, Yuan Y, Chen Y, Lu Y, Cheng J, Liu J. Peritoneal M2 macrophage-derived extracellular vesicles as natural multitarget nanotherapeutics to attenuate cytokine storms after severe infections. J Control Release 2022; 349:118-132. [PMID: 35792186 PMCID: PMC9257240 DOI: 10.1016/j.jconrel.2022.06.063] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 12/04/2022]
Abstract
Cytokine storms are a primary cause of multiple organ damage and death after severe infections, such as SARS-CoV-2. However, current single cytokine-targeted strategies display limited therapeutic efficacy. Here, we report that peritoneal M2 macrophage-derived extracellular vesicles (M2-EVs) are multitarget nanotherapeutics that can be used to resolve cytokine storms. In detail, primary peritoneal M2 macrophages exhibited superior anti-inflammatory potential than immobilized cell lines. Systemically administered M2-EVs entered major organs and were taken up by phagocytes (e.g., macrophages). M2-EV treatment effectively reduced excessive cytokine (e.g., TNF-α and IL-6) release in vitro and in vivo, thereby attenuating oxidative stress and multiple organ (lung, liver, spleen and kidney) damage in endotoxin-induced cytokine storms. Moreover, M2-EVs simultaneously inhibited multiple key proinflammatory pathways (e.g., NF-κB, JAK-STAT and p38 MAPK) by regulating complex miRNA-gene and gene-gene networks, and this effect was collectively mediated by many functional cargos (miRNAs and proteins) in EVs. In addition to the direct anti-inflammatory role, human peritoneal M2-EVs expressed angiotensin-converting enzyme 2 (ACE2), a receptor of SARS-CoV-2 spike protein, and thus could serve as nanodecoys to prevent SARS-CoV-2 pseudovirus infection in vitro. As cell-derived nanomaterials, the therapeutic index of M2-EVs can be further improved by genetic/chemical modification or loading with specific drugs. This study highlights that peritoneal M2-EVs are promising multifunctional nanotherapeutics to attenuate infectious disease-related cytokine storms.
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