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Wagner Y, Adam D, Pomeranz Engelberg G, Pomeranz A, Messinger YH. HLH Syndrome in a Community Hospital: The Challenge of an Early Diagnosis. Pediatric Health Med Ther 2024; 15:111-120. [PMID: 38469429 PMCID: PMC10926863 DOI: 10.2147/phmt.s446681] [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: 11/14/2023] [Accepted: 02/16/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyperinflammatory cytokine storm. It can be secondary to infections, malignancies, autoimmune diseases, or the manifestation of genetic disorders, including primary immune deficiency. HLH requires a high index of suspicion and is challenging for community hospitals. Methods Medical records of children with HLH admitted to the Meir Medical Center in Israel between 2014 and 2017 were reviewed. Results Nine children met ≥5/8 HLH-2004 criteria. The median age was 1.1 year, and 78% of the patients were aged <2 years. All patients had prolonged fever, cytopenia, and elevated soluble interleukin-2 receptor, and 89% had elevated ferritin levels. Of three children who underwent gene panel evaluation, one had heterozygote genetic variants of UNC13D and STXBP2 of unclear significance, whereas the other two had no variants. Infection was identified in 8 of 9 patients: adenovirus, HHV6, EBV, and Streptococcus Group A. Only 2 patients received HLH-2004 therapy (dexamethasone, etoposide, cyclosporin-A) and the others received dexamethasone and/or intravenous gamma globulins (IVIG), with rapid resolution of fever (median 2 days). One patient (11%) died of Pseudomonas septicemia and multiorgan failure. At a median follow-up of 7 years (range 2.6-8.1 years), all others (8/9) are long-term survivors with no recurrent HLH, but 2 patients developed adenovirus-related bronchiolitis obliterans. Conclusion Children presenting with prolonged fever and abnormal blood counts should be evaluated with ferritin, triglycerides, and fibrinogen levels which indicate possible HLH. Early intervention with corticosteroids and/or IVIG may prevent deterioration, spare them from chemotherapy and provide time for more elaborate testing to identify true HLH. Unfortunately, mortality remains a significant risk for these children.
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Affiliation(s)
- Yuval Wagner
- Pediatric Department, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dganit Adam
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Intensive Care Unit, Meir Medical Center, Kfar Saba, Israel
| | - Galit Pomeranz Engelberg
- Pediatric Department, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avishalom Pomeranz
- Pediatric Department, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav H Messinger
- Department of Hematology-Oncology, Children’s Hospitals of Minnesota, Minneapolis, MN, USA
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Felipe Almira E, Sequí Sabater JM, Vilaplana Mora I, Angelats Romero CM, Sequí-Canet JM. Hemophagocytic-like syndrome secondary to group A streptococcal pharyngitis. An Pediatr (Barc) 2024; 100:212-213. [PMID: 38403535 DOI: 10.1016/j.anpede.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/15/2024] [Indexed: 02/27/2024] Open
Affiliation(s)
- Elena Felipe Almira
- Servicio Pediatría, Hospital Universitario Francisco de Borja, Gandia, Valencia, Spain.
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Benevenuta C, Mussinatto I, Orsi C, Timeus FS. Secondary hemophagocytic lymphohistiocytosis in children (Review). Exp Ther Med 2023; 26:423. [PMID: 37602304 PMCID: PMC10433411 DOI: 10.3892/etm.2023.12122] [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: 12/29/2022] [Accepted: 06/16/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by hyperinflammation in an uncontrolled and ineffective immune response. Despite great improvement in diagnosis and treatment, it still represents a challenge in clinical management, with poor prognosis in the absence of an aggressive therapeutic approach. The present literature review focuses on secondary HLH at pediatric age, which represents a heterogeneous group in terms of etiology and therapeutic approach. It summarizes the most recent evidence on epidemiology, pathophysiology, diagnosis, treatment and prognosis, and provides a detailed description and comparison of the major subtypes of secondary HLH. Finally, it addresses the open questions with a focus on diagnosis and new treatment insights.
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Affiliation(s)
- Chiara Benevenuta
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Ilaria Mussinatto
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Cecilia Orsi
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Fabio S. Timeus
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
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Zhang J, Wang J, Gan J, Luo R, Chen X. The first case of Streptococcus intermedius brain abscess with hemophagocytic histiocytosis. BMC Infect Dis 2022; 22:627. [PMID: 35850669 PMCID: PMC9290246 DOI: 10.1186/s12879-022-07600-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially life-threatening immune syndrome associated with an excessive systemic inflammatory response. Viral infection caused HLH is the most common secondary HLH, but there are relatively few reports of HLH caused by bacterial infection. The present study is the first case of HLH caused by Streptococcus intermedia meningitis. Case presentation The patient is an 11-year-old and 9-month-old boy. The main symptoms are fever, headache, and vomiting. The imaging finding of the brain is cerebritis and brain abscess. The cerebrospinal fluid (CSF) routine test showed increased nucleated cells, but the smear and culture of CSF were negative. The metagenomics next-generation sequencing (mNGS) of CSF detected Streptococcus intermedius, and the body temperature of the children returned to normal after antibiotic treatment according to etiology. One week later, the child developed fever again, with Kawasaki disease-like manifestations. After high-dose immunoglobulin therapy, the body temperature returned to normal again. The routine blood test showed a progressive decrease in leukocytes and platelets, and bone marrow biopsy detected histiocytes phagocytosed blood cells. Then infection-associated hemophagocytic syndrome (IAHS) was diagnosed, high-dose methylprednisolone and sequential therapy were given and the patient’s recovery was encouraging. Conclusions Our case shows that HLH can also be secondary to Streptococcus intermediate infection, and early bone marrow biopsy is the golden standard for HLH diagnosis. mNGS can improve the detection sensitivity for pathogens when traditional pathogenic tests are negative. Conventional chemotherapy regimens may not be required for IAHS when high-dose glucocorticoids and immunoglobulin therapy are effective.
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Affiliation(s)
- Jia Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, 610041, China
| | - Jianjun Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, 610041, China
| | - Jing Gan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, 610041, China
| | - Rong Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, 610041, China
| | - Xiaolu Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, 610041, China. .,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China. .,Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Chengdu, 610041, China.
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Perricone C, Bartoloni E, Bursi R, Cafaro G, Guidelli GM, Shoenfeld Y, Gerli R. COVID-19 as part of the hyperferritinemic syndromes: the role of iron depletion therapy. Immunol Res 2020. [PMID: 32681497 DOI: 10.22541/au.158880283.34604328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
SARS-CoV-2 infection is characterized by a protean clinical picture that can range from asymptomatic patients to life-threatening conditions. Severe COVID-19 patients often display a severe pulmonary involvement and develop neutrophilia, lymphopenia, and strikingly elevated levels of IL-6. There is an over-exuberant cytokine release with hyperferritinemia leading to the idea that COVID-19 is part of the hyperferritinemic syndrome spectrum. Indeed, very high levels of ferritin can occur in other diseases including hemophagocytic lymphohistiocytosis, macrophage activation syndrome, adult-onset Still's disease, catastrophic antiphospholipid syndrome and septic shock. Numerous studies have demonstrated the immunomodulatory effects of ferritin and its association with mortality and sustained inflammatory process. High levels of free iron are harmful in tissues, especially through the redox damage that can lead to fibrosis. Iron chelation represents a pillar in the treatment of iron overload. In addition, it was proven to have an anti-viral and anti-fibrotic activity. Herein, we analyse the pathogenic role of ferritin and iron during SARS-CoV-2 infection and propose iron depletion therapy as a novel therapeutic approach in the COVID-19 pandemic.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, 5265601, Tel-Hashomer, Israel
- The Mosaic of Autoimmunity Project, Saint Petersburg University, Saint Petersburg, Russia
- Ministry of Health of the Russian Federation, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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Perricone C, Bartoloni E, Bursi R, Cafaro G, Guidelli GM, Shoenfeld Y, Gerli R. COVID-19 as part of the hyperferritinemic syndromes: the role of iron depletion therapy. Immunol Res 2020; 68:213-224. [PMID: 32681497 PMCID: PMC7366458 DOI: 10.1007/s12026-020-09145-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SARS-CoV-2 infection is characterized by a protean clinical picture that can range from asymptomatic patients to life-threatening conditions. Severe COVID-19 patients often display a severe pulmonary involvement and develop neutrophilia, lymphopenia, and strikingly elevated levels of IL-6. There is an over-exuberant cytokine release with hyperferritinemia leading to the idea that COVID-19 is part of the hyperferritinemic syndrome spectrum. Indeed, very high levels of ferritin can occur in other diseases including hemophagocytic lymphohistiocytosis, macrophage activation syndrome, adult-onset Still's disease, catastrophic antiphospholipid syndrome and septic shock. Numerous studies have demonstrated the immunomodulatory effects of ferritin and its association with mortality and sustained inflammatory process. High levels of free iron are harmful in tissues, especially through the redox damage that can lead to fibrosis. Iron chelation represents a pillar in the treatment of iron overload. In addition, it was proven to have an anti-viral and anti-fibrotic activity. Herein, we analyse the pathogenic role of ferritin and iron during SARS-CoV-2 infection and propose iron depletion therapy as a novel therapeutic approach in the COVID-19 pandemic.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, 5265601, Tel-Hashomer, Israel
- The Mosaic of Autoimmunity Project, Saint Petersburg University, Saint Petersburg, Russia
- Ministry of Health of the Russian Federation, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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Terashima S, Hayakawa K, Saito F, Wada D, Iwamura H, Kuro A, Ozaki Y, Nakamori Y, Ishii K, Kuwagata Y. Hemophagocytic syndrome with severe sepsis caused by Capnocytophaga canimorsus. Am J Emerg Med 2020; 38:1540.e5-1540.e8. [PMID: 32197716 DOI: 10.1016/j.ajem.2020.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022] Open
Abstract
Capnocytophaga canimorsus, commonly transmitted by dog bites, can cause severe sepsis, and the mortality rate is very high. We experienced a case of hemophagocytic lymphohistiocytosis (HLH) complicated by severe sepsis caused by C. canimorsus. A 58-year-old man with no remarkable medical history was admitted to another hospital with fever and mild consciousness disorder developed 3 days after being bitten by his dog. The next day, the patient developed disseminated intravascular coagulation and shock and was transferred to our emergency medical center. Blood tests showed hyperferritinemia and cytopenia, and bone marrow aspiration was performed. As a result, we diagnosed severe sepsis and HLH. Once antibiotic and steroid therapy was started, the patient's infection and cytopenia improved. Unfortunately, the patient's fingers and toes required amputation, but his life was saved, and he was discharged from hospital. Because HLH may be hidden in such cases, it may be necessary to measure serum ferritin and perform bone marrow aspiration if hyperferritinemia is suspected.
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Affiliation(s)
- Shinya Terashima
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Koichi Hayakawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Fukuki Saito
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Daiki Wada
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Hiromu Iwamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Atsuyuki Kuro
- Department of Plastic and Reconstructive Surgery, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Yujiro Ozaki
- Department of Plastic and Reconstructive Surgery, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Yasushi Nakamori
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Kazuyoshi Ishii
- Department of Hematology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka 570-8507, Japan.
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
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Hemophagocytic lymphohistiocytosis complicating invasive pneumococcal disease: a pediatric case report. BMC Pediatr 2020; 20:15. [PMID: 31931763 PMCID: PMC6956486 DOI: 10.1186/s12887-020-1915-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 01/07/2020] [Indexed: 12/29/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an infrequent but life-threatening disease due to excessive immune activation. Secondary HLH can be triggered by infections, autoimmune diseases, and malignant diseases. Streptococcus pneumoniae is a pathogenic bacterium responsible for invasive pneumococcal disease (IPD) such as meningitis and bacteremia. Although the pneumococcal conjugate vaccine (PCV) has led to reductions in IPD incidence, cases of IPD caused by serotypes not included in PCV are increasing. There are few reports of secondary HLH caused by IPD in previously healthy children. We herein report a rare case of a previously healthy boy with secondary HLH complicating IPD of serotype 23A, which is not included in the pneumococcal 13-valent conjugate vaccine (PCV-13). Case presentation An 11-month-old boy who had received three doses of PCV-13 was hospitalized with prolonged fever, bilateral otitis media, neutropenia and elevated C-reactive protein (CRP) levels. Blood culture on admission revealed S. pneumoniae, leading to a diagnosis of IPD. HLH was diagnosed based on a prolonged fever, neutropenia, anemia, hepatosplenomegaly, hemophagocytosis in the bone marrow, and elevated serum levels of triglycerides, ferritin, and soluble interleukin-2 receptor. He received broad-spectrum antibiotics and intravenous immunoglobulins for IPD and high-dose steroid pulse therapy and cyclosporine A for HLH; thereafter, his fever resolved, and laboratory findings improved. The serotype of the isolated S. pneumoniae was 23A, which is not included in PCV-13. Conclusions It is important to consider secondary HLH as a complication of IPD cases with febrile cytopenia or hepatosplenomegaly, and appropriate treatment for HLH should be started without delay.
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