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Carol HA, Mayer AS, Zhang MS, Dang V, Varghese J, Martinez Z, Schneider C, Baker JE, Tsoukas P, Behrens EM, Cron RQ, Diorio C, Henderson LA, Schulert G, Lee P, Kernan KF, Canna SW. Hyperferritinemia screening to aid identification and differentiation of patients with hyperinflammatory disorders. RESEARCH SQUARE 2024:rs.3.rs-4523502. [PMID: 38978562 PMCID: PMC11230465 DOI: 10.21203/rs.3.rs-4523502/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
High ferritin is an important and sensitive biomarker for hemophagocytic lymphohistiocytosis (HLH), a diverse and deadly group of cytokine storm syndromes. Early action to prevent immunopathology in HLH often includes empiric immunomodulation, which can complicate etiologic work-up and prevent collection of early/pre-treatment research samples. To address this, we instituted an alert system where serum ferritin > 1000ng/mL triggered real-time chart review, assessment of whether the value reflected "inflammatory hyperferritnemia (IHF)", and biobanking of remnant samples from consenting IHF patients. We extracted relevant clinical data; periodically measured serum total IL-18, IL-18 binding protein (IL-18BP), and CXCL9; retrospectively classified patients by etiology into infectious, rheumatic, or immune dysregulation; and subjected a subgroup of samples to a 96-analyte biomarker screen. 180 patients were identified, 30.5% of which had IHF. Maximum ferritin levels were significantly higher in patients with IHF than with either hemoglobinopathy or transplant, and highly elevated total IL-18 levels were distinctive to patients with Stills Disease and/or Macrophage Activation Syndrome (MAS). Multi-analyte analysis showed elevation in proteins associated with cytotoxic lymphocytes in all IHF samples when compared to healthy controls and depression of proteins such as ANGPT1 and VEGFR2 in samples from hyperferritinemic sepsis patients relative to non-sepsis controls. This single-center, real-time IFH screen proved feasible and efficient, validated prior observations about the specificity of IL-18, enabled early sample collection from a complex population, suggested a unique vascular biomarker signature in hyperferritinemic sepsis, and expanded our understanding of IHF heterogeneity.
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Affiliation(s)
- Hallie A Carol
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Adam S Mayer
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Michael S Zhang
- Division of Pediatric Allergy/Immunology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Vinh Dang
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Jemy Varghese
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Zachary Martinez
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia
| | - Corinne Schneider
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Joy Elizabeth Baker
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center
| | - Paul Tsoukas
- Division of Pediatric Rheumatology, Hospital for Sick Children,Toronto, ON
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Randy Q Cron
- Division of Pediatric Rheumatology, The University of Alabama at Birmingham
| | - Caroline Diorio
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia
| | | | - Grant Schulert
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center
| | - Pui Lee
- Division of Immunology, Boston Children's Hospital
| | - Kate F Kernan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Scott W Canna
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
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2
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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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3
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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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Mendes-Filho SPDM, de Souza Pinheiro R, Martins FS, Giroldi PJ, e Melo RH, de Oliveira EL, dos Santos AB, Medeiros DCO, Lopes JA, Chaves YO, Zuliani JP, Nogueira PA. Kinetics of IL-6, C-reactive Protein and Fibrinogen Levels in COVID-19 Outpatients Who Evolved to Hypoxemia. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2024; 17:2632010X231222795. [PMID: 38188270 PMCID: PMC10768631 DOI: 10.1177/2632010x231222795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
Introduction Despite the efficacy of the COVID-19, the search for improvements in the management of severe/critical cases continues to be important. The aim is to demonstrate the kinetics of 4 serological markers in patients with COVID-19 who evolved in hypoxemia. Methods From June to December 2020, the Health Secretariat of Rondônia State, Brazil, established a home medical care service team (HMCS) that provided clinical follow-up for health professionals and military personnel with COVID-19. The clinical and laboratory monitoring was individualized at home by a nursing and medical team. In addition to laboratory parameters, C-reactive protein (CRP), interleukin-6 (IL-6), fibrinogen, and D-dimer levels were periodically taken to monitor the evolution of treatment. Results Of 218 patients telemonitored, 48 patients needed special care by the HMCS team due to shortness of breath. Chest tomography showed multiple ground-glass shadows and lung parenchymal condensations that was compatible with secondary bacterial infection associated with leukocytosis, for which antibiotics were prescribed. The symptoms were accompanied by increases of CRP and IL-6 levels followed by fibrinogen after a few days, for which an anticoagulant therapy was included. Thirty-three patients evolved to improvements in clinical signs and laboratory results. Between the sixth and eighth day of illness, 15 patients presented signs of hypoxemia with low O2 saturation accompanied with an increase in the respiratory rate, with some of them requiring oxygen therapy. As they did not present signs of clinical severity, but their laboratory markers showed an abrupt IL-6 peak that was higher than the increase in CRP and a new alteration in fibrinogen levels, they received a supplemental dose of anticoagulant and a high dose of corticosteroids, which resulted in clinical improvement. Conclusion Our study demonstrates that monitoring of IL-6 and CRP may identify precocious hypoxemia in COVID-19 patients and prevented the progressive deterioration of the lung injury.
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Affiliation(s)
| | - Rebeca de Souza Pinheiro
- Programa de Pós-graduação de Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus/AM, Brazil
| | - Fernanda Simão Martins
- Serviço de Assistência Médica Domiciliar (SAMD), Secretaria Estadual da Saúde (SESAU), Porto Velho/RO, Brazil
| | - Paulo Jose Giroldi
- Laboratório Estadual de Patologia e Análises Clínicas (LEPAC), Porto Velho/RO, Brazil
| | - Raul Honorato e Melo
- Serviço de Assistência Médica Domiciliar (SAMD), Secretaria Estadual da Saúde (SESAU), Porto Velho/RO, Brazil
- Hospital Cemetron, Porto Velho/RO, Brazil
| | | | - Anibal Borin dos Santos
- Serviço de Assistência Médica Domiciliar (SAMD), Secretaria Estadual da Saúde (SESAU), Porto Velho/RO, Brazil
| | | | | | - Yury Oliveira Chaves
- Instituto Leônidas e Maria Deane (ILMD), Fundação Oswaldo Cruz – Amazonas (FIOCRUZ – AMAZONAS), Manaus/AM, Brazil
| | | | - Paulo Afonso Nogueira
- Programa de Pós-graduação de Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus/AM, Brazil
- Instituto Leônidas e Maria Deane (ILMD), Fundação Oswaldo Cruz – Amazonas (FIOCRUZ – AMAZONAS), Manaus/AM, Brazil
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus/AM, Brazil
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5
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Green A, Rachoin JS, Schorr C, Dellinger P, Casey JD, Park I, Gupta S, Baron RM, Shaefi S, Hunter K, Leaf DE. Timing of invasive mechanical ventilation and death in critically ill adults with COVID-19: A multicenter cohort study. PLoS One 2023; 18:e0285748. [PMID: 37379286 PMCID: PMC10306211 DOI: 10.1371/journal.pone.0285748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality. MATERIALS AND METHODS The data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model. RESULTS Among the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]). CONCLUSIONS In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.
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Affiliation(s)
- Adam Green
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jean-Sebastien Rachoin
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Christa Schorr
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Phil Dellinger
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Rebecca M. Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Krystal Hunter
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
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Vordenbäumen S, Feist E, Rech J, Fleck M, Blank N, Haas JP, Kötter I, Krusche M, Chehab G, Hoyer B, Kiltz U, Fell D, Reiners J, Weseloh C, Schneider M, Braun J. Diagnosis and treatment of adult-onset Still's disease: a concise summary of the German society of rheumatology S2 guideline. Z Rheumatol 2023; 82:81-92. [PMID: 36520170 DOI: 10.1007/s00393-022-01294-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Stefan Vordenbäumen
- Rheinisches Rheuma-Zentrum St. Elisabeth-Hospital Meerbusch, Meerbusch-Lank, Germany. .,Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.
| | - Eugen Feist
- Rheumazentrum Sachsen-Anhalt, Helios Fachklinik Vogelsang-Gommern, Kooperationspartner der Otto-von-Guericke Universität Magdeburg, Vogelsang-Gommern, Germany
| | - Jürgen Rech
- Medizinische Klinik 3-Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, 91054, Erlangen, Germany
| | - Martin Fleck
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Regensburg, Germany.,Klinik für Rheumatologie/Klinische Immunologie, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Norbert Blank
- Medizinische Klinik 5, Sektion Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Johannes-Peter Haas
- Kinderklinik Garmisch-Partenkirchen gGmbH, Deutsches Zentrum für Kinder- und Jugendrheumatologie, Garmisch-Partenkirchen, Germany
| | - Ina Kötter
- III. Medizinische Klinik und Poliklinik, Sektion für Rheumatologie und Entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik, Sektion für Rheumatologie und Entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Gamal Chehab
- Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Bimba Hoyer
- Medizinische Fakultät, Sektion Rheumatologie und klinische Immunologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Uta Kiltz
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany.,Rheumazentrum Ruhrgebiet am Marien Hospital, Universitätsklinik der Ruhr-Universität Bochum, Herne, Germany
| | - Dorothea Fell
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Germany
| | - Julia Reiners
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Germany
| | | | - Matthias Schneider
- Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.,Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany
| | - Jürgen Braun
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany.,Rheumazentrum Ruhrgebiet am Marien Hospital, Universitätsklinik der Ruhr-Universität Bochum, Herne, Germany
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7
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Jungwirth-Weinberger A, Bendich I, Westrich GH, Su EP, Valle AGD, Boettner F. Preoperative ferritin and hemoglobin levels are lower in patients with a history of COVID-19 but blood loss and transfusion requirements are not increased. Arch Orthop Trauma Surg 2023; 143:311-315. [PMID: 34302523 PMCID: PMC8308077 DOI: 10.1007/s00402-021-04082-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/18/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION A history of COVID-19 (Coronavirus Disease 2019), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have an impact on hemoglobin and ferritin levels predisposing patients to increased blood transfusion requirements following total joint arthroplasty (TJA). The current study compares ferritin levels, hemoglobin levels, and transfusion rates between SARS-CoV-2 IgG positive and SARS-CoV-2 IgG negative TJA patients. MATERIALS AND METHODS Preoperative ferritin levels, pre- and postoperative hemoglobin levels, postoperative change in hemoglobin, and transfusion rates of 385 consecutive SARS-CoV-2 IgG positive patients undergoing TJA were compared to those of 5156 consecutive SARS-CoV-2 IgG negative patients undergoing TJA. RESULTS Preoperative hemoglobin levels were significantly lower in SARS-CoV-2 IgG positive patients [13.3 g/dL (range 8.9-17.7 g/dL)] compared to 13.5 g/dl (7.3-18.3 g/dL; p value 0.03). Ferritin levels were significantly lower in SARS-CoV-2 IgG positive patients (mean of 106.1 ng/ml (2.1-871.3.3 ng/ml) vs. 123.7 ng/ml (1.4-1985 ng/ml) (p value 0.02)). Hemoglobin on postoperative day (POD) one, after four-six weeks, and transfusion rates did not differ between the two groups. CONCLUSION Although preoperative hemoglobin and ferritin levels are lower in SARS-CoV2 IgG positive patients, there was no difference in hemoglobin on POD one, recovery of hemoglobin levels at four-six weeks postoperatively, and transfusion rates after surgery. Routine ferritin testing prior to TJA is not recommended in SARS-CoV-2 IgG positive patients.
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Affiliation(s)
- Anna Jungwirth-Weinberger
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Cantonal Hospital Baden, Im Ergel 1, CH-5404 Baden, Switzerland
| | - Ilya Bendich
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - Edwin P. Su
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Differential Diagnosis of Hyperferritinemia in Critically Ill Patients. J Clin Med 2022; 12:jcm12010192. [PMID: 36614993 PMCID: PMC9821140 DOI: 10.3390/jcm12010192] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/16/2022] [Accepted: 12/24/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Elevated serum ferritin is a common condition in critically ill patients. It is well known that hyperferritinemia constitutes a good biomarker for hemophagocytic lymphohistiocytosis (HLH) in critically ill patients. However, further differential diagnoses of hyperferritinemia in adult critically ill patients remain poorly investigated. We sought to systematically investigate hyperferritinemia in adult critically ill patients without HLH. METHODS In this secondary analysis of a retrospective observational study, patients ≥18 years admitted to at least one adult intensive care unit at Charité-Universitätsmedizin Berlin between January 2006 and August 2018, and with hyperferritinemia of ≥500 μg/L were included. Patients with HLH were excluded. All patients were categorized into non-sepsis, sepsis, and septic shock. They were also classified into 17 disease groups, based on their ICD-10 codes, and pre-existing immunosuppression was determined. Uni- and multivariable linear regression analyses were performed in all patients. RESULTS A total of 2583 patients were analyzed. Multivariable linear regression analysis revealed positive associations of maximum SOFA score, sepsis or septic shock, liver disease (except hepatitis), and hematological malignancy with maximum ferritin. T/NK cell lymphoma, acute myeloblastic leukemia, Kaposi's sarcoma, acute or subacute liver failure, and hepatic veno-occlusive disease were positively associated with maximum ferritin in post-hoc multivariable linear regression analysis. CONCLUSIONS Sepsis or septic shock, liver disease (except hepatitis) and hematological malignancy are important differential diagnoses in hyperferritinemic adult critically ill patients without HLH. Together with HLH, they complete the quartet of important differential diagnoses of hyperferritinemia in adult critically ill patients. As these conditions are also related to HLH, it is important to apply HLH-2004 criteria for exclusion of HLH in hyperferritinemic patients. Hyperferritinemic critically ill patients without HLH require quick investigation of differential diagnoses.
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New Iron Metabolic Pathways and Chelation Targeting Strategies Affecting the Treatment of All Types and Stages of Cancer. Int J Mol Sci 2022; 23:ijms232213990. [PMID: 36430469 PMCID: PMC9696688 DOI: 10.3390/ijms232213990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
There is new and increasing evidence from in vitro, in vivo and clinical studies implicating the pivotal role of iron and associated metabolic pathways in the initiation, progression and development of cancer and in cancer metastasis. New metabolic and toxicity mechanisms and pathways, as well as genomic, transcription and other factors, have been linked to cancer and many are related to iron. Accordingly, a number of new targets for iron chelators have been identified and characterized in new anticancer strategies, in addition to the classical restriction of/reduction in iron supply, the inhibition of transferrin iron delivery, the inhibition of ribonucleotide reductase in DNA synthesis and high antioxidant potential. The new targets include the removal of excess iron from iron-laden macrophages, which affects anticancer activity; the modulation of ferroptosis; ferritin iron removal and the control of hyperferritinemia; the inhibition of hypoxia related to the role of hypoxia-inducible factor (HIF); modulation of the function of new molecular species such as STEAP4 metalloreductase and the metastasis suppressor N-MYC downstream-regulated gene-1 (NDRG1); modulation of the metabolic pathways of oxidative stress damage affecting mitochondrial function, etc. Many of these new, but also previously known associated iron metabolic pathways appear to affect all stages of cancer, as well as metastasis and drug resistance. Iron-chelating drugs and especially deferiprone (L1), has been shown in many recent studies to fulfill the role of multi-target anticancer drug linked to the above and also other iron targets, and has been proposed for phase II trials in cancer patients. In contrast, lipophilic chelators and their iron complexes are proposed for the induction of ferroptosis in some refractory or recurring tumors in drug resistance and metastasis where effective treatments are absent. There is a need to readdress cancer therapy and include therapeutic strategies targeting multifactorial processes, including the application of multi-targeting drugs involving iron chelators and iron-chelator complexes. New therapeutic protocols including drug combinations with L1 and other chelating drugs could increase anticancer activity, decrease drug resistance and metastasis, improve treatments, reduce toxicity and increase overall survival in cancer patients.
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10
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11
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Extreme Hyperferritinemia: Causes and Prognosis. J Clin Med 2022; 11:jcm11185438. [PMID: 36143085 PMCID: PMC9505036 DOI: 10.3390/jcm11185438] [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: 08/28/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/20/2022] Open
Abstract
The significance of extreme hyperferritinemia and its association with certain diagnoses and prognoses are not well characterized. We performed a retrospective analysis of adult patients with at least one total serum ferritin (TSF) measurement ≥ 5000 µg/L over 2 years, in three university hospitals. Conditions associated with hyperferritinemia were collected, and patients were classified into 10 etiological groups. Intensive care unit (ICU) transfer and mortality rates were recorded. A total of 495 patients were identified, of which 56% had a TSF level between 5000 and 10,000 µg/L. There were multiple underlying causes in 81% of the patients. The most common causes were infections (38%), hemophagocytic lymphohistiocytosis (HLH, 18%), and acute hepatitis (14%). For TSF levels > 10,000 µg/L, there were no solid cancer or hematological malignancy without another cause of hyperferritinemia. Isolated iron-overload syndromes never exceeded TSF levels > 15,000 µg/L. Extreme hyperferritinemia (TSF levels > 25,000 µg/L) was associated with only four causes: HLH, infections, acute hepatitis and cytokine release syndromes. A total of 32% of patients were transferred to an ICU, and 28% died. Both ICU transfer rate and mortality were statistically associated with ferritin levels. An optimized threshold of 13,405 μg/L was the best predictor for the diagnosis of HLH, with a sensitivity of 76.4% and a specificity of 79.3%. Hyperferritinemia reflects a variety of conditions, but only four causes are associated with extreme hyperferritinemia, in which HLH and acute hepatitis are the most common. Extreme hyperferritinemia has a poor prognosis with increased mortality.
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Sagy I, Finkel-Oron A, Naamany E, Barski L, Abu-Shakra M, Molad Y, Shiber S. Diagnostic utility of clinical characteristics, laboratory tests, and serum ferritin in diagnosis of adult-onset Still disease. Medicine (Baltimore) 2022; 101:e30152. [PMID: 36042585 PMCID: PMC9410682 DOI: 10.1097/md.0000000000030152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The diagnosis of adult-onset Still disease (AOSD) is challenging with ambiguous clinical presentation and no specific serological markers. We aim to evaluate the diagnostic utility of clinical, laboratory and serum ferritin features in established AOSD patients. We included all patients >18 years who were admitted to 2 tertiary medical centers (2003-2019) with serum ferritin above 1000 ng/mL. AOSD patients and non-AOSD controls were matched in 1:4 ratio for age and sex. The primary outcomes were sensitivity, specificity, positive/negative likelihood ratio and area under the curve (AUC) using clinical and laboratory characteristics based on the Yamaguchi classification criteria, in addition to serum ferritin. We identified 2658 patients with serum ferritin above 1000 ng/m, of whom 36 diagnosed with AOSD and 144 non-AOSD matched controls. Presence of arthralgia/arthritis showed the highest sensitivity (0.74), specificity (0.93), positive likelihood ratio (10.69), negative likelihood ratio (0.27) and AUC (0.83, 95% confidence interval 0.74-0.92) to the diagnosis of AOSD. On the other hand, serum ferritin showed variation and poorer results, depends on the chosen ferritin cutoff. Joint involvement showed the best diagnostic utility to establish the diagnosis of AOSD. Although clinicians use often elevated ferritin levels as an anchor to AOSD, the final diagnosis should be based on thorough clinical evaluation.
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Affiliation(s)
- Iftach Sagy
- Rheumatic Diseases Unit, Soroka University Medical Center, Beer Sheva, Israel
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alona Finkel-Oron
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eviatar Naamany
- Internal Medicine Division, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Barski
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Mahmoud Abu-Shakra
- Rheumatic Diseases Unit, Soroka University Medical Center, Beer Sheva, Israel
- Internal Medicine Division, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachaf Shiber
- Institute of Rheumatology, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Internal Medicine Division, Rabin Medical Center, Beilinsone Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Iftach Sagy, MD, PhD, Clinical Research Center, Soroka University Medical Center, POB 151, Beer-Sheva 84101, Israel (e-mail: )
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13
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Hsu CC, Senussi NH, Fertrin KY, Kowdley KV. Iron overload disorders. Hepatol Commun 2022; 6:1842-1854. [PMID: 35699322 PMCID: PMC9315134 DOI: 10.1002/hep4.2012] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/06/2022] [Accepted: 04/16/2022] [Indexed: 01/19/2023] Open
Abstract
Iron overload disorders represent a variety of conditions that lead to increased total body iron stores and resultant end-organ damage. An elevated ferritin and transferrin-iron saturation can be commonly encountered in the evaluation of elevated liver enzymes. Confirmatory homeostatic iron regulator (HFE) genetic testing for C282Y and H63D, mutations most encountered in hereditary hemochromatosis, should be pursued in evaluation of hyperferritinemia. Magnetic resonance imaging with quantitative assessment of iron content or liver biopsy (especially if liver disease is a cause of iron overload) should be used as appropriate. A secondary cause for iron overload should be considered if HFE genetic testing is negative for the C282Y homozygous or C282Y/H63D compound heterozygous mutations. Differential diagnosis of secondary iron overload includes hematologic disorders, iatrogenic causes, or chronic liver diseases. More common hematologic disorders include thalassemia syndromes, myelodysplastic syndrome, myelofibrosis, sideroblastic anemias, sickle cell disease, or pyruvate kinase deficiency. If iron overload has been excluded, evaluation for causes of hyperferritinemia should be pursued. Causes of hyperferritinemia include chronic liver disease, malignancy, infections, kidney failure, and rheumatic conditions, such as adult-onset Still's disease or hemophagocytic lymphohistiocytosis. In this review, we describe the diagnostic testing of patients with suspected hereditary hemochromatosis, the evaluation of patients with elevated serum ferritin levels, and signs of secondary overload and treatment options for those with secondary iron overload.
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Affiliation(s)
- Christine C Hsu
- Medstar Georgetown University HospitalMedstar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Nizar H Senussi
- Gastroenterology and HepatologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Kleber Y Fertrin
- Division of HematologyDepartment of MedicineUniversity of WashingtonWashingtonUSA
| | - Kris V Kowdley
- Liver Institute Northwest and Elson S. Floyd College of MedicineWashington State UniversityWashingtonUSA
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14
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Targeting ferroptosis as a vulnerability in pulmonary diseases. Cell Death Dis 2022; 13:649. [PMID: 35882850 PMCID: PMC9315842 DOI: 10.1038/s41419-022-05070-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 01/21/2023]
Abstract
Ferroptosis is an iron-dependent regulated cell death marked by excessive oxidative phospholipids (PLs). The polyunsaturated fatty acids-containing phospholipids (PUFA-PLs) are highly susceptible to lipid peroxidation under oxidative stress. Numerous pulmonary diseases occurrences and degenerative pathologies are driven by ferroptosis. This review discusses the role of ferroptosis in the pathogenesis of pulmonary diseases including asthma, lung injury, lung cancer, fibrotic lung diseases, and pulmonary infection. Additionally, it is proposed that targeting ferroptosis is a potential treatment for pulmonary diseases, particularly drug-resistant lung cancer or antibiotic-resistant pulmonary infection, and reduces treatment-related adverse events.
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15
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Kontoghiorghes GJ. Deferiprone: A Forty-Year-Old Multi-Targeting Drug with Possible Activity against COVID-19 and Diseases of Similar Symptomatology. Int J Mol Sci 2022; 23:ijms23126735. [PMID: 35743183 PMCID: PMC9223898 DOI: 10.3390/ijms23126735] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 02/01/2023] Open
Abstract
The need for preparing new strategies for the design of emergency drug therapies against COVID-19 and similar diseases in the future is rather urgent, considering the high rate of morbidity and especially mortality associated with COVID-19, which so far has exceeded 18 million lives. Such strategies could be conceived by targeting the causes and also the serious toxic side effects of the diseases, as well as associated biochemical and physiological pathways. Deferiprone (L1) is an EMA- and FDA-approved drug used worldwide for the treatment of iron overload and also other conditions where there are no effective treatments. The multi-potent effects and high safety record of L1 in iron loaded and non-iron loaded categories of patients suggests that L1 could be developed as a “magic bullet” drug against COVID-19 and diseases of similar symptomatology. The mode of action of L1 includes antiviral, antimicrobial, antioxidant, anti-hypoxic and anti-ferroptotic effects, iron buffering interactions with transferrin, iron mobilizing effects from ferritin, macrophages and other cells involved in the immune response and hyperinflammation, as well as many other therapeutic interventions. Similarly, several pharmacological and other characteristics of L1, including extensive tissue distribution and low cost of production, increase the prospect of worldwide availability, as well as many other therapeutic approach strategies involving drug combinations, adjuvant therapies and disease prevention.
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Affiliation(s)
- George J Kontoghiorghes
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol 3021, Cyprus
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16
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Karim A, Bajbouj K, Qaisar R, Hall AC, Hamad M. The role of disrupted iron homeostasis in the development and progression of arthropathy. J Orthop Res 2022; 40:1243-1250. [PMID: 35289955 DOI: 10.1002/jor.25323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
Arthropathy or joint disease leads to significant pain and disability irrespective of etiology. Clinical and experimental evidence point to the presence of considerable links between arthropathy and iron overload. Previous work has suggested that iron accumulation in the joints is often associated with increased oxidative stress, disrupted matrix metabolism, and cartilage degeneration. However, key issues regarding the role of iron overload in the pathogenesis of arthropathy remain ambiguous. For example, significant gaps in our knowledge of the primary cellular targets of iron overload-induced damage and the exact molecular mechanism through which disrupted iron homeostasis leads to joint damage still exist. The exact signaling pathway that links iron metabolism and cellular damage in arthropathy also remains largely unmapped. In this review, we focus on the relationship between iron overload and arthropathy with special emphasis on the adversarial relationship between iron that accumulates in the joints over time and cartilage homeostasis. A better understanding of the mechanisms and pathways underlying iron-induced cartilage degeneration may help in defining new prognostic markers and therapeutic targets in arthropathy.
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Affiliation(s)
- Asima Karim
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Khuloud Bajbouj
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Rizwan Qaisar
- Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Andrew C Hall
- Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Mawieh Hamad
- Department of Medical Laboratory Sciences, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
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17
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Olympic Cycle Comparison of the Nutritional and Cardiovascular Health Status of an Elite-Level Female Swimmer: Case Study Report from Slovenia. Sports (Basel) 2022; 10:sports10050063. [PMID: 35622472 PMCID: PMC9143311 DOI: 10.3390/sports10050063] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023] Open
Abstract
Monitoring the many aspects that are crucial to an athlete’s performance progress is vital for further training planning and for the development of performance and the sport. We evaluated a four-year change (2018 vs. 2022) in the current nutritional and cardiovascular health status of the most successful elite-level female swimmer in Slovenia. Body composition and dietary intake were assessed using dual-energy X-ray absorptiometry and a standardized food questionnaire. The concentration of blood lipids, blood pressure, and serum micronutrients (B12, 25(OH)D), potassium, calcium, phosphorus, magnesium, and iron) were measured. The four-year comparison showed an improved body composition status (i.e., increased body mass and decreased body fat (percentage and mass), increased lean soft tissue and total bone mineral density (BMD) (i.e., significantly decreased BMD of a left femoral neck and increased BMD of a spine and head)). We also measured an improvement in the cardiovascular health status of some markers (i.e., decreased total cholesterol, triglycerides, and blood pressure but increased low-density lipoprotein cholesterol), most likely due to the differences in assessed dietary intake (i.e., lower carbohydrate intake, higher total and saturated fat intake, and lower sodium intake). Notably, nutrient intakes that are generally of concern (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), vitamin B12 and D, calcium, iron, and zinc (except for fiber intake)) were all within recommended ranges. However, the athlete’s vitamin K and potassium intake were not adequate. Furthermore, in 2018, the athlete did not consume dietary supplements, while she now regularly uses several dietary supplements, including EPA and DHA omega-3, vitamin D, multivitamins, carbohydrate powder, and sports drink. Moreover, from the micronutrient serum, only iron levels deviated from the reference values (37 μmol/L vs. 10.7–28.6 μmol/L). The presented screening example using valid, sensitive, and affordable methods and with rapid organizational implementation may be a viable format for regular monitoring.
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18
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Han HJ, Parks AL, Shah MP, Hsu G, Santhosh L. An Elusive Seizure. Neurohospitalist 2022; 12:188-194. [PMID: 34950412 PMCID: PMC8689556 DOI: 10.1177/19418744211018096] [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: 01/03/2023] Open
Abstract
We present a case of a healthy 62-year-old woman who developed recurrent seizures preceded by subacute cognitive slowing, ataxia, night sweats, and weight loss. She was found to have cytopenias, multifocal T2/FLAIR hyperintensities on magnetic resonance imaging (MRI), and magnetic susceptibility artifact lesions on susceptibility weighted imaging (SWI). Her symptoms, imaging and laboratory abnormalities all improved with high-doses of steroids and intravenous immunoglobulin (IVIG). But recurred several weeks after completing treatment. Despite extensive work-up, she required multiple hospitalizations and repeat diagnostic studies to arrive at a diagnosis. With an expert discussant in hematology and oncology, we review the differential diagnosis and stepwise approach of unexplained neuro-inflammatory syndromes with cytopenias and systemic symptoms. Our case highlights how time, empiric treatment response, and repeated diagnostic studies refine differential diagnoses and subsequent evaluation. After revealing the diagnosis, we discuss the heterogenous clinical manifestations of this disease process.
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Affiliation(s)
- Harry J. Han
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Anna L. Parks
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Maulik P. Shah
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Gerald Hsu
- Department of Medicine, University of California, San Francisco, CA, USA,Division of Hematology/Oncology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA. Han is now with Harvard Interprofessional Palliative Care Fellowship, Massachusetts General Hospital and the Dana Farber Cancer Institute, Boston, MA, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California, San Francisco, CA, USA,Lekshmi Santhosh, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco CA 94143, USA.
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19
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Yamindago A, Lee N, Lee N, Jo Y, Woo S, Yum S. Fluoxetine in the environment may interfere with the neurotransmission or endocrine systems of aquatic animals. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2021; 227:112931. [PMID: 34715500 DOI: 10.1016/j.ecoenv.2021.112931] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/28/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
Antidepressants are extensively used to treat the symptoms of depression in humans, and the environmentally discharged drugs potentially threaten aquatic organisms. In this study, the acute toxic effects of fluoxetine (FLX) were investigated in two aquatic organisms, the freshwater polyp (Hydra magnipapillata) and Javanese medaka (Oryzias javanicus). The median lethal concentration (LC50) of FLX in H. magnipapillata was 3.678, 3.082, and 2.901 mg/L after 24, 48, and 72 h, respectively. Morphological observations of the FLX-exposed H. magnipapillata showed that 1.5 mg/L FLX induced the contraction of the tentacles and body column. The LC50 of FLX in O. javanicus was 2.046, 1.936, 1.532, and 1.237 mg/L after 24, 48, 72, and 96 h, respectively. Observation of the behavior of the FLX-exposed fish showed that FLX reduced their swimming performance at a minimum concentration of 10 µg/L. The half-maximal effective concentration (EC50) of FLX for swimming behavior in O. javanicus was 0.135, 0.108, and 0.011 mg/L after 12, 24, and 96 h, respectively. Transcriptomic analyses indicated that FLX affects various physiological and metabolic processes in both species. FLX exposure induced oxidative stress, reproductive deficiency, abnormal pattern formation, DNA damage, and neurotransmission disturbance in H. magnipapillata, whereas it adversely affected O. javanicus by inducing oxidative stress, DNA damage, endoplasmic reticulum stress, and mRNA instability. Neurotransmission-based behavioral changes and endocrine disruption were strongly suspected in the FLX-exposed fish. These results suggest that FLX affects the behavior and metabolic regulation of aquatic organisms.
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Affiliation(s)
- Ade Yamindago
- CORECT Research Group, Faculty of Fisheries and Marine Science, Universitas Brawijaya, Malang 65145, Indonesia; Study Program of Marine Science, Faculty of Fisheries and Marine Science, Universitas Brawijaya, Malang 65145, Indonesia.
| | - Nayun Lee
- Ecological Risk Research Division, Korea Institute of Ocean Science and Technology, Geoje 53201, Republic of Korea
| | - Nayoung Lee
- Ecological Risk Research Division, Korea Institute of Ocean Science and Technology, Geoje 53201, Republic of Korea
| | - Yejin Jo
- Ecological Risk Research Division, Korea Institute of Ocean Science and Technology, Geoje 53201, Republic of Korea
| | - Seonock Woo
- Marine Biotechnology Research Center, Korea Institute of Ocean Science and Technology, Busan 49111, Republic of Korea
| | - Seungshic Yum
- Ecological Risk Research Division, Korea Institute of Ocean Science and Technology, Geoje 53201, Republic of Korea; KIOST School, University of Science and Technology, Geoje 53201, Republic of Korea.
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高 伟, 石 茂, 张 海, 吴 春, 朱 继. [Relationship between marked hyperferritinemia and hemophagocytic lymphohistiocytosis]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:921-927. [PMID: 34650295 PMCID: PMC8517670 DOI: 10.19723/j.issn.1671-167x.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the relationship between marked hyperferritinemia (MHF) and hemophagocytic lymphohistiocytosis(HLH). METHODS The clinical data of 123 patients with MHF admitted to Peking University People's Hospital from January 2017 to September 2018 were collected, including demographics, baseline characteristics, signs and symptoms, blood routine, blood biochemistry, coagulation function parameters, such as prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib), d-dimer (D-D), fibrin degradation product (FDP), blood ferritin, natural killer (NK) cell activity, soluble interleukin (IL)-2 receptor and bone marrow examination. According to the diagnosis of HLH, the patients were divided into HLH group and non HLH group. The patients were divided into death group and survival group according to the 3-month follow-up results. The groups were compared and statistically analyzed. RESULTS In the 123 patients with MHF, the average age was (44.2±17.4) years with a male/female ratio of 1.3 ∶1. The most common causes were hematolo-gic malignancies, rheumatologic and inflammatory disorders, iron overload, and HLH. HLH was enriched as the ferritin increased, and the HLH ratios were 28.8%, 40.0%, 54.5%, 50.0%, 50.0% in ferritin value of 10 000-19 999, 20 000-29 999, 30 000-39 999, 40 000-49 999 μg/L, more than 50 000 μg/L respectively. There were 46 cases of HLH, among which 15 cases were secondary to malignancies, 14 cases secondary to rheumatologic disorders, 2 cases secondary to infection, and 15 cases with no clear precipitating cause. There were significant differences between the HLH group and non-HLH group in hepatomegaly, splenomegaly, lymphadenectasis, albumin (ALB), fibrinogen(Fib), P < 0.05, and no significant differences in age, gender, fever, disturbance of consciousness, ferritin level on presentation, maximum ferritin level, cytopenia in 2 or more cell lines, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL), triglyceride (TG), coagulation parameters (PT, APTT, D-D, FDP, exception of Fib), and mortality rate (P > 0.05). There were significant differences between the death group and survival group in disturbance of consciousness, platelet count, PT, TBIL, and DBIL (P < 0.05), but no significant differences in age, gender, fever, hepatomegaly, splenomegaly, lymphadenectasis, ferritin level on presentation, maximum ferritin level, neutrophils, hemoglobin, ALT, AST, ALB, TG, coagulation parameters (Fib, APTT, D-D, FDP, exception of PT) and the HLH ratio (P > 0.05). CONCLUSION HLH was enriched as the ferritin increased, but marked hyperferritinemia was not specific for HLH in adults.
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Affiliation(s)
- 伟波 高
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 茂静 石
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 海燕 张
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 春波 吴
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
| | - 继红 朱
- />北京大学人民医院急诊科, 北京 100044Department of Emergency, Peking University People's Hospital, Beijing 100044, China
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21
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Ruiz-Ordoñez I, Puerta-Sarmiento G, Muñoz-Patiño V, Giraldo-Fernández V, Nieto-Aristizábal I, Vivas ÁJ, Tobón GJ. Description of the Etiologies, Clinical Characteristics, and Outcomes in Patients with Hyperferritinemia in a Colombian Tertiary Hospital. J Appl Lab Med 2021; 6:1571-1579. [PMID: 34324687 DOI: 10.1093/jalm/jfab076] [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: 04/09/2021] [Accepted: 06/02/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND This study analyzes the clinical characteristics, outcomes, and conditions associated with hyperferritinemia (≥5000 ng/mL) in a high-complexity center in Colombia. METHODS This retrospective and descriptive study was performed between 2011 and 2020, at the Fundación Valle del Lili, Cali, Colombia, by reviewing medical charts from patients who had serum ferritin measurements equal to or greater than 5000 ng/mL. RESULTS We found 350 reports of ferritin values ≥5000 ng/mL, corresponding to 317 patients, with a median ferritin value of 8789 (6001-15 373) ng/mL. The most frequent etiologies were infection (n = 198, 56.57%), hematologic disorders (n = 104, 29.71%), and blood transfusion (n = 98, 28.00%). These last 2 etiologies cooccurred in 37 (10.57%) cases. The main clinical signs accompanying hyperferritinemia were fever in 199 (56.86%) cases, multiorgan involvement in 125 (35.71%), and hepatomegaly in 95 (27.14%) cases. Ninety-four (29.65%) patients died in the hospital, and 11 (3.47%) died within 30 days after medical discharge, mainly due to infection (n = 51, 48.57%). Intrahospital mortality was associated with significantly higher ferritin levels (10 846, IQR: 6425-23 459) than survival (8452, IQR: 5980-13 932) (P = 0.018). CONCLUSIONS Hyperferritinemia is related to many underlying causes, with infection being the principal cause in our cohort, followed by hematologic disorders. Additionally, in-hospital mortality was related to higher ferritin levels.
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Affiliation(s)
- Ingrid Ruiz-Ordoñez
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Germán Puerta-Sarmiento
- Universidad Icesi, Medical School, Cali, Colombia.,Fundación Valle del Lili, Unit of Rheumatology, Cali, Colombia
| | | | | | | | - Álvaro J Vivas
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Gabriel J Tobón
- Fundación Valle del Lili, Unit of Rheumatology, Cali, Colombia.,Universidad Icesi, CIRAT: Centro de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional, Cali, Colombia
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22
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Daniłowicz-Szymanowicz L, Świątczak M, Sikorska K, Starzyński RR, Raczak A, Lipiński P. Pathogenesis, Diagnosis, and Clinical Implications of Hereditary Hemochromatosis-The Cardiological Point of View. Diagnostics (Basel) 2021; 11:diagnostics11071279. [PMID: 34359361 PMCID: PMC8304945 DOI: 10.3390/diagnostics11071279] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 01/25/2023] Open
Abstract
Hereditary hemochromatosis (HH) is a genetic disease leading to excessive iron absorption, its accumulation, and oxidative stress induction causing different organ damage, including the heart. The process of cardiac involvement is slow and lasts for years. Cardiac pathology manifests as an impaired diastolic function and cardiac hypertrophy at first and as dilatative cardiomyopathy and heart failure with time. From the moment of heart failure appearance, the prognosis is poor. Therefore, it is crucial to prevent those lesions by upfront therapy at the preclinical phase of the disease. The most useful diagnostic tool for detecting cardiac involvement is echocardiography. However, during an early phase of the disease, when patients do not present severe abnormalities in serum iron parameters and severe symptoms of other organ involvement, heart damage may be overlooked due to the lack of evident signs of cardiac dysfunction. Considerable advancement in echocardiography, with particular attention to speckle tracking echocardiography, allows detecting discrete myocardial abnormalities and planning strategy for further clinical management before the occurrence of substantial heart damage. The review aims to present the current state of knowledge concerning cardiac involvement in HH. In addition, it could help cardiologists and other physicians in their everyday practice with HH patients.
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Affiliation(s)
- Ludmiła Daniłowicz-Szymanowicz
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Dębinki 7 St., 80-211 Gdańsk, Poland;
- Correspondence: ; Tel.: +48-349-39-10
| | - Michał Świątczak
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Dębinki 7 St., 80-211 Gdańsk, Poland;
| | - Katarzyna Sikorska
- Department of Tropical Medicine and Epidemiology, Medical University of Gdańsk, Dębinki 7 St., 80-211 Gdańsk, Poland;
| | - Rafał R. Starzyński
- Department of Molecular Biology, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Wólka Kosowska, 05-552 Jastrzębiec, Poland; (R.R.S.); (P.L.)
| | - Alicja Raczak
- Clinical Psychology Department, Faculty of Health Sciences, Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Paweł Lipiński
- Department of Molecular Biology, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Wólka Kosowska, 05-552 Jastrzębiec, Poland; (R.R.S.); (P.L.)
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Evaluation of hyperferritinemia causes in rheumatology practice: a retrospective, single-center experience. Rheumatol Int 2021; 41:1617-1624. [PMID: 34213581 PMCID: PMC8252695 DOI: 10.1007/s00296-021-04935-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/21/2021] [Indexed: 12/15/2022]
Abstract
Hyperferritinemia may develop due to various reasons such as inflammation, infection, or malignancy. The purpose of the study to explore the prevalence and to figure out the causes of general hyperferritinemia and extreme hyperferritinemia as detected through the ferritin measurements requested by the rheumatology department. Adult patients at the age of 18 years and older with at least one serum ferritin level measurement at or above 500 ng/mL as requested by the rheumatology department between January 2010 and December 2019 were evaluated retrospectively. Hyperferritinemia was detected in 4.7% of 11,498 serum ferritin tests. The mean age of 242 patients found to have hyperferritinemia was 53.7 ± 17.1 years; of the patients, 63.2% were female, and the mean serum ferritin value was 2820 ± 5080 ng/mL. The most common cause of hyperferritinemia was rheumatological diseases with a ratio of 59.1%, which was followed by infections, iron overload, and solid malignancy. Among the rheumatologic diseases, adult-onset Still’s disease (AOSD), rheumatoid arthritis, and vasculitis were the cause accounting for hyperferritinemia. Ferritin levels were significantly higher in the AOSD group compared to the other rheumatologic disease groups (p < 0.0001). While extreme hyperferritinemia (ferritin ≥ 10,000 ng/mL) rate in our cohort was 0.2%, the most common cause was AOSD (15/17). In patients with hyperferritinemia, 3 month mortality was found to be 8.7%. CRP level was identified as the only independent predictor for the 3 month mortality in all patients [OR 1.088 (95% CI 1.004–1.178), p = 0.039]. Although rheumatologic disease activation and infections are the most common causes, the other causes should also be considered for the differential diagnosis.
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Prone Positioning and Survival in Mechanically Ventilated Patients With Coronavirus Disease 2019-Related Respiratory Failure. Crit Care Med 2021; 49:1026-1037. [PMID: 33595960 PMCID: PMC8277560 DOI: 10.1097/ccm.0000000000004938] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Therapies for patients with respiratory failure from coronavirus disease 2019 are urgently needed. Early implementation of prone positioning ventilation improves survival in patients with acute respiratory distress syndrome, but studies examining the effect of proning on survival in patients with coronavirus disease 2019 are lacking. Our objective was to estimate the effect of early proning initiation on survival in patients with coronavirus disease 2019-associated respiratory failure. DESIGN Data were derived from the Study of the Treatment and Outcomes in Critically Ill Patients with coronavirus disease 2019, a multicenter cohort study of critically ill adults with coronavirus disease 2019 admitted to 68 U.S. hospitals. Using these data, we emulated a target trial of prone positioning ventilation by categorizing mechanically ventilated hypoxemic (ratio of Pao2 over the corresponding Fio2 ≤ 200 mm Hg) patients as having been initiated on proning or not within 2 days of ICU admission. We fit an inverse probability-weighted Cox model to estimate the mortality hazard ratio for early proning versus no early proning. Patients were followed until death, hospital discharge, or end of follow-up. SETTING ICUs at 68 U.S. sites. PATIENTS Critically ill adults with laboratory-confirmed coronavirus disease 2019 receiving invasive mechanical ventilation with ratio of Pao2 over the corresponding Fio2 less than or equal to 200 mm Hg. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 2,338 eligible patients, 702 (30.0%) were proned within the first 2 days of ICU admission. After inverse probability weighting, baseline and severity of illness characteristics were well-balanced between groups. A total of 1,017 (43.5%) of the 2,338 patients were discharged alive, 1,101 (47.1%) died, and 220 (9.4%) were still hospitalized at last follow-up. Patients proned within the first 2 days of ICU admission had a lower adjusted risk of death compared with nonproned patients (hazard ratio, 0.84; 95% CI, 0.73-0.97). CONCLUSIONS In-hospital mortality was lower in mechanically ventilated hypoxemic patients with coronavirus disease 2019 treated with early proning compared with patients whose treatment did not include early proning.
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Melo AKG, Milby KM, Caparroz ALMA, Pinto ACPN, Santos RRP, Rocha AP, Ferreira GA, Souza VA, Valadares LDA, Vieira RMRA, Pileggi GS, Trevisani VFM. Biomarkers of cytokine storm as red flags for severe and fatal COVID-19 cases: A living systematic review and meta-analysis. PLoS One 2021; 16:e0253894. [PMID: 34185801 PMCID: PMC8241122 DOI: 10.1371/journal.pone.0253894] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 06/16/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To describe the laboratory parameters and biomarkers of the cytokine storm syndrome associated with severe and fatal COVID-19 cases. METHODS A search with standardized descriptors and synonyms was performed on November 28th, 2020 of the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, LILACS, and IBECS to identify studies of interest. Grey literature searches and snowballing techniques were additionally utilized to identify yet-unpublished works and related citations. Two review authors independently screened the retrieved titles and abstracts, selected eligible studies for inclusion, extracted data from the included studies, and then assessed the risk of bias using the Newcastle-Ottawa Scale. Eligible studies were those including laboratory parameters-including serum interleukin-6 levels-from mild, moderate, or severe COVID-19 cases. Laboratory parameters, such as interleukin-6, ferritin, hematology, C-Reactive Protein, procalcitonin, lactate dehydrogenase, aspartate aminotransferase, creatinine, and D-dimer, were extracted from the studies. Meta-analyses were conducted using the laboratory data to estimate mean differences with associated 95% confidence intervals. DATA SYNTHESIS The database search yielded 9,620 records; 40 studies (containing a total of 9,542 patients) were included in the final analysis. Twenty-one studies (n = 4,313) assessed laboratory data related to severe COVID-19 cases, eighteen studies (n = 4,681) assessed predictors for fatal COVID-19 cases and one study (n = 548) assessed laboratory biomarkers related to severe and fatal COVID-19 cases. Lymphopenia, thrombocytopenia, and elevated levels of interleukin-6, ferritin, D-dimer, aspartate aminotransferase, C-Reactive-Protein, procalcitonin, creatinine, neutrophils and leucocytes were associated with severe and fatal COVID-19 cases. CONCLUSIONS This review points to interleukin-6, ferritin, leukocytes, neutrophils, lymphocytes, platelets, C-Reactive Protein, procalcitonin, lactate dehydrogenase, aspartate aminotransferase, creatinine, and D-dimer as important biomarkers of cytokine storm syndrome. Elevated levels of interleukin-6 and hyperferritinemia should be considered as red flags of systemic inflammation and poor prognosis in COVID-19.
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Affiliation(s)
- Ana Karla G. Melo
- Division of Rheumatology, Department of Clinical Medicine, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Keilla M. Milby
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Ana Luiza M. A. Caparroz
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Pediatric Rheumatology, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Ana Carolina P. N. Pinto
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Biological and Health Sciences, Universidade Federal do Amapá, Macapá, AP, Brazil
- Fulbright Alumna at University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Rodolfo R. P. Santos
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Data Science, Synova Health, Campinas, SP, Brazil
| | - Aline P. Rocha
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Gilda A. Ferreira
- Department of Lokomotor System, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Viviane A. Souza
- Department of Clinical Medicine, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brazil
| | | | - Rejane M. R. A. Vieira
- Department of Clinical Medicine, Universidade Estadual do Ceará, Fortaleza, CE, Brazil
- Department of Clinical Medicine, Universidade de Fortaleza, Fortaleza, CE, Brazil
| | - Gecilmara S. Pileggi
- Department of Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Virgínia F. M. Trevisani
- Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Rheumatology, Universidade de Santo Amaro, São Paulo, SP, Brazil
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Annous Y, Manning S, Khoujah D. Ferritin, fever, and frequent visits: Hyperferritinemic syndromes in the emergency department. Am J Emerg Med 2021; 48:249-254. [PMID: 34000525 DOI: 10.1016/j.ajem.2021.04.088] [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: 12/11/2020] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/15/2022] Open
Abstract
Fever of unknown origin (FUO) is defined as persistent fevers without an identifiable cause despite extensive medical workup. Emergency physicians caring for patients reporting a persistent, nonspecific, febrile illness should carefully consider potentially serious non-infectious causes of FUO. We present a case of a 35-year-old man who presented to the emergency department (ED) three times over a 10-day period for persistent febrile illness and was ultimately diagnosed with Adult-Onset Still's Disease (AOSD) after a serum ferritin level was found to be over 42,000 μg/L. AOSD, along with macrophage activation syndrome, catastrophic antiphospholipid syndrome, and septic shock comprise the four hyperferritinemic syndromes. These are potentially life-threatening febrile illnesses that characteristically present with elevated ferritin levels. In this article, we highlight the value of a serum ferritin level in the workup of a patient with prolonged febrile illness and its utility in facilitating early diagnosis and prompt treatment of hyperferritinemic syndromes in the ED.
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Affiliation(s)
- Youssef Annous
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Sara Manning
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Israel A, Bornstein G, Gilad L, Shechtman L, Furie N, Ben-Zvi I, Grossman C. Clinical and prognostic significance of elevated ferritin levels in hospitalised adults. Postgrad Med J 2021; 98:622-625. [PMID: 33846221 DOI: 10.1136/postgradmedj-2021-139832] [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: 01/28/2021] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF THE STUDY Elevated ferritin levels are associated with a variety of infectious, malignant and inflammatory diseases. We aimed to investigate the prognostic value of markedly elevated ferritin levels in hospitalised patients with various medical conditions. STUDY DESIGN Retrospective analysis of patients with a ferritin level higher than 2000 ng/mL hospitalised in Sheba Medical Center between 1 January 2007 and 31 December 2015. Medical conditions of these patients were recorded. In-hospital, 30-day and 1-year mortality rates were evaluated according to ferritin ranges and clinical categories. RESULTS The study included 722 patients (63.4% men) with a mean age of 63.9±16.7 years. The most common clinical conditions associated with markedly elevated ferritin were infectious diseases and malignancies. The highest mean ferritin levels were associated with rheumatological/inflammatory conditions (16 241.3 ng/dL), particularly in patients with macrophage activation syndrome (MAS) (96 615.5 ng/dL). In-hospital, 30-day and 1-year mortality rates were 32.3%, 46.7% and 70.8%, respectively. The highest in-hospital, 30-day and 1-year mortality rates were observed among patients with solid malignancies (40.1%, 64.7% and 90.3%, respectively), whereas the lowest rates were found among patients with rheumatological/inflammatory conditions, including MAS (21.4%, 38.1% and 45.2%, respectively). Ferritin levels were not associated with mortality. CONCLUSIONS In hospitalised patients, ferritin levels higher than 2000 ng/mL are mainly associated with infectious and malignant diseases but do not predict mortality.
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Affiliation(s)
- Ariel Israel
- Department of Family Medicine, Clalit Health Services, Tel Aviv, Israel
| | - Gil Bornstein
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Lee Gilad
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Liran Shechtman
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Furie
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilan Ben-Zvi
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Chagai Grossman
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Hemophagocytic Lymphohistiocytosis in the Emergency Department: Recognizing and Evaluating a Hidden Threat. J Emerg Med 2021; 60:743-751. [PMID: 33745765 PMCID: PMC7972988 DOI: 10.1016/j.jemermed.2021.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/04/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematologic disorder resulting from an ineffective and pathologic activation of the immune response system that may mimic common emergency department presentations, including sepsis, acute liver failure, disseminated intravascular coagulation, and flu-like illnesses such as coronavirus disease 2019 (COVID-19). Objective This narrative review provides a summary of the disease and recommendations for the recognition and diagnostic evaluation of HLH with a focus on the emergency clinician. Discussion Though the condition is rare, mortality rates are high, ranging from 20% to 80% and increasing with delays in treatment. Importantly, HLH has been recognized as a severe variation of the cytokine storm associated with COVID-19. Common features include a history of infection or malignancy, fever, splenomegaly or hepatomegaly, hyperferritinemia, cytopenias, coagulopathies, abnormal liver enzymes, and hypertriglyceridemia. Using specific features of the history, physical examination, laboratory studies, and tools such as the HScore, HLH-2004/2009, and hyperferritinemia thresholds, the emergency clinician can risk-stratify patients and admit for definitive testing. Once diagnosed, disease specific treatment can be initiated. Conclusion This review describes the relevant pathophysiology, common presentation findings, and a framework for risk stratification in the emergency department.
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Han ZB, Wu J, Liu J, Li HM, Guo K, Sun T. Adult-onset Still's disease evolving with multiple organ failure and death: A case report and review of the literature. World J Clin Cases 2021; 9:886-897. [PMID: 33585636 PMCID: PMC7852636 DOI: 10.12998/wjcc.v9.i4.886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/28/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disease, which is characterized by daily fever and arthritis, with an evanescent rash and neutrophilic leukocytosis. To date, there has been no definite laboratory or imaging test available for diagnosing AOSD; the diagnosis is one of exclusion, which can be very challenging. In particular, AOSD patients may experience different complications affecting their clinical picture, management, and prognosis. The treatment of AOSD remains largely empirical and involves therapeutic agents.
CASE SUMMARY We report the case of a 36-year-old woman who presented with fever, red rash, arthralgia, and sore throat. Her serum ferritin level and white blood cell count were markedly elevated, and the first diagnosis 22 years prior was "juvenile rheumatoid arthritis of systemic type". The patient was treated with prednisone, sulfasalazine, methotrexate, and leflunomide. After remission of her symptoms, the patient stopped taking the medications, and the disease recurred. Ultimately, the patient was diagnosed with adult-onset Still's disease. Relapse occurred several times due to self-medication withdrawal, and an interleukin-6 antagonist (tocilizumab/Actemra) was administered to control the disease. Recently, she was hospitalized because an incision did not heal, and the patient suddenly developed high fever and diarrhea during hospitalization. The patient's disease progressed violently and quickly developed into macrophage activation syndrome, disseminated intravascular coagulation, shock, and multiple organ failure. The patient had sudden cardiac arrest, and she died despite emergency rescue efforts.
CONCLUSION AOSD patients need regular follow-up in the long-term treatment process, and must press formulary standard medication, and do not voluntarily withdraw or reduce the dose. Otherwise it may cause disease back-and-forth or serious life-threatening complications. Meanwhile, strict management of trauma, infections, tumors, and other diseases may contribute to improved outcomes in patients with complications.
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Affiliation(s)
- Zhong-Bin Han
- Department of Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, Liaoning Province, China
| | - Ju Wu
- Department of Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, Liaoning Province, China
| | - Jing Liu
- Department of ICU, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, Liaoning Province, China
| | - He-Ming Li
- Department of Oncology, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, Liaoning Province, China
| | - Kai Guo
- Department of Surgery, Second People's Hospital of Jinzhong City, Jinzhong 030600, Shanxin Province, China
| | - Tong Sun
- Department of ICU, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, Liaoning Province, China
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Ishihara A, Yamauchi T, Ikeda K, Fukuyoshi Y, Yokoyama T, Yonemura Y, Uchiba M, Matsui H. Glycosylated ferritin as an improved marker for post-transfusion iron overload. Int J Hematol 2021; 113:537-546. [PMID: 33400141 DOI: 10.1007/s12185-020-03056-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 11/25/2022]
Abstract
Red blood cell (RBC) transfusion is an effective therapy for anemia, but repeated transfusions may cause iron overload-related damage to various organs. Iron chelation therapy, now widely available for patients who have received transfusions, is expected to reduce organ damage even in patients who received many transfusions. Therefore, determining when to start iron chelation therapy is important. In guidelines for iron chelation therapy, the serum ferritin level has been widely accepted as a practical marker for estimating iron overload. However, guidelines recommend multiple measurements of serum ferritin, because levels often fluctuate. Here, we investigated the usefulness of glycosylated ferritin as a marker of iron overload using a cohort consisted of 103 patients who had a total ferritin value over 1000 ng/mL. We found that the volume of RBCs transfused was clearly associated with the glycosylated ferritin level. We also found that acute inflammation, as represented by C-reactive protein values, was associated with increased non-glycosylated ferritin and that patients with hematopoietic diseases had higher glycosylated ferritin levels, possibly because of repeated RBC transfusions. We thus conclude that glycosylated ferritin may be an improved marker for predicting iron overload status.
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Affiliation(s)
- Ayako Ishihara
- Department of Clinical Laboratory Medicine, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan
| | - Tsuyuko Yamauchi
- Department of Clinical Laboratory Medicine, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan
| | - Katsuyoshi Ikeda
- Department of Medical Technology, Kumamoto Health Science University, Kumamoto, Japan
| | - Yoko Fukuyoshi
- Department of Clinical Laboratory Medicine, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan
| | - Toshiro Yokoyama
- Department of Clinical Laboratory Medicine, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan
| | - Yuji Yonemura
- Department of Transfusion Medicine and Cell Therapy, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan
- Department of Hematology, Rheumatology and Infectious Disease, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Mitsuhiro Uchiba
- Department of Transfusion Medicine and Cell Therapy, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan
- Department of Hematology, Rheumatology and Infectious Disease, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirotaka Matsui
- Department of Clinical Laboratory Medicine, Kumamoto University Hospital, Kumamoto University, Kumamoto, Japan.
- Department of Molecular Laboratory Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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Gupta S, Wang W, Hayek SS, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Finkel D, Green A, Mallappallil M, Faugno AJ, Zhang J, Velez JCQ, Shaefi S, Parikh CR, Charytan DM, Athavale AM, Friedman AN, Redfern RE, Short SAP, Correa S, Pokharel KK, Admon AJ, Donnelly JP, Gershengorn HB, Douin DJ, Semler MW, Hernán MA, Leaf DE. Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19. JAMA Intern Med 2021; 181:41-51. [PMID: 33080002 PMCID: PMC7577201 DOI: 10.1001/jamainternmed.2020.6252] [Citation(s) in RCA: 324] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/10/2020] [Indexed: 01/08/2023]
Abstract
Importance Therapies that improve survival in critically ill patients with coronavirus disease 2019 (COVID-19) are needed. Tocilizumab, a monoclonal antibody against the interleukin 6 receptor, may counteract the inflammatory cytokine release syndrome in patients with severe COVID-19 illness. Objective To test whether tocilizumab decreases mortality in this population. Design, Setting, and Participants The data for this study were derived from a multicenter cohort study of 4485 adults with COVID-19 admitted to participating intensive care units (ICUs) at 68 hospitals across the US from March 4 to May 10, 2020. Critically ill adults with COVID-19 were categorized according to whether they received or did not receive tocilizumab in the first 2 days of admission to the ICU. Data were collected retrospectively until June 12, 2020. A Cox regression model with inverse probability weighting was used to adjust for confounding. Exposures Treatment with tocilizumab in the first 2 days of ICU admission. Main Outcomes and Measures Time to death, compared via hazard ratios (HRs), and 30-day mortality, compared via risk differences. Results Among the 3924 patients included in the analysis (2464 male [62.8%]; median age, 62 [interquartile range {IQR}, 52-71] years), 433 (11.0%) received tocilizumab in the first 2 days of ICU admission. Patients treated with tocilizumab were younger (median age, 58 [IQR, 48-65] vs 63 [IQR, 52-72] years) and had a higher prevalence of hypoxemia on ICU admission (205 of 433 [47.3%] vs 1322 of 3491 [37.9%] with mechanical ventilation and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of <200 mm Hg) than patients not treated with tocilizumab. After applying inverse probability weighting, baseline and severity-of-illness characteristics were well balanced between groups. A total of 1544 patients (39.3%) died, including 125 (28.9%) treated with tocilizumab and 1419 (40.6%) not treated with tocilizumab. In the primary analysis, during a median follow-up of 27 (IQR, 14-37) days, patients treated with tocilizumab had a lower risk of death compared with those not treated with tocilizumab (HR, 0.71; 95% CI, 0.56-0.92). The estimated 30-day mortality was 27.5% (95% CI, 21.2%-33.8%) in the tocilizumab-treated patients and 37.1% (95% CI, 35.5%-38.7%) in the non-tocilizumab-treated patients (risk difference, 9.6%; 95% CI, 3.1%-16.0%). Conclusions and Relevance Among critically ill patients with COVID-19 in this cohort study, the risk of in-hospital mortality in this study was lower in patients treated with tocilizumab in the first 2 days of ICU admission compared with patients whose treatment did not include early use of tocilizumab. However, the findings may be susceptible to unmeasured confounding, and further research from randomized clinical trials is needed.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Wei Wang
- Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S. Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L. Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K. Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
- Department of Internal Medicine, Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J. Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine Center, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Diana Finkel
- Department of Medicine, Division of Infectious Diseases, New Jersey Medical School, Rutgers University, Newark
| | - Adam Green
- Division of Critical Care, Cooper University Health Care, Camden, New Jersey
| | - Mary Mallappallil
- Division of Nephrology, Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York
| | - Anthony J. Faugno
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jingjing Zhang
- Division of Nephrology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana
- Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David M. Charytan
- Division of Nephrology, Department of Medicine, NYU (New York University) Langone Medical Center, New York, New York
| | | | - Allon N. Friedman
- Department of Medicine, Indiana University School of Medicine/Indiana University Health, Indianapolis
| | | | | | - Simon Correa
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kapil K. Pokharel
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - John P. Donnelly
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - David J. Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miguel A. Hernán
- Department of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard-MIT (Massachusetts Institute of Technology) Program in Health Sciences and Technology, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Going Skin Deep: Excavating a Diagnosis of Intravascular Large B Cell Lymphoma. J Gen Intern Med 2020; 35:3368-3371. [PMID: 32815059 PMCID: PMC7661630 DOI: 10.1007/s11606-020-06141-1] [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] [Received: 01/11/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
A fever of unknown origin is often pursued diagnostically under the framework of infectious, rheumatologic, and neoplastic causes. When encephalopathy ensues, the differential diagnosis narrows, but can remain elusive, particularly when dealing with rare diseases. We present the case of a patient with fever of unknown origin and intermittent encephalopathy that spanned multiple hospital admissions and ultimately yielded a diagnosis of intravascular large B cell lymphoma complicated by hemophagocytic lymphohistiocytosis. We review the varying presentations of this disease, when to consider this as a diagnosis, and how to most accurately make the diagnosis.
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Sarangi R, Pathak M, Padhi S, Mahapatra S. Ferritin in hemophagocytic lymphohistiocytosis (HLH): current concepts and controversies. Clin Chim Acta 2020; 510:408-415. [PMID: 32745577 DOI: 10.1016/j.cca.2020.07.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/11/2022]
Affiliation(s)
- RajLaxmi Sarangi
- Department of Biochemistry, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
| | - Mona Pathak
- Department of Biostatistics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
| | - Somanath Padhi
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.
| | - Srikrushna Mahapatra
- Department of Biochemistry, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
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Goldhaber G, Segal G, Dagan A. Hyperferritinemia in the elderly can differentiate the bad from the worst: A retrospective cohort analysis. Medicine (Baltimore) 2020; 99:e21419. [PMID: 32756143 PMCID: PMC7402730 DOI: 10.1097/md.0000000000021419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Both total-body iron stores and inflammation influence the concentration of ferritin in the blood. Ferritin as an inflammatory marker might serve as a prognostic marker in the elderly. Therefore, we characterized the clinical circumstances and long-term outcomes of hyperferritinemia (> 1000 μg/L) in hospitalized elderly patients.A retrospective analysis of elderly (> 70 years) inpatients with ferritin levels of > 1000 μg/L in a tertiary medical center during a 3-year period. We obtained both laboratory and clinical data, assessing the potential association of high ferritin levels with long-term mortality.Overall, 242 patients (median age 79 years; median ferritin level 1436 μg/L) met the inclusion criteria and were followed for a median time of 18.6 months. Clinical outcomes were dismal for the whole cohort: the diagnosis of solid malignancy occurred in 23.5% of cases while 31% had a severe infection (ranging from sepsis to septic shock). The median survival time of the whole cohort was 4.7 months only. Within the cohort, risk stratification was feasible: higher ferritin levels differentiate between groups of patients who had a poor prognosis (with either septic shock or solid malignancy) and those who had a relatively favorable prognosis (patients diagnosed as suffering from sepsis without shock and patients with iatrogenic causes for hyperferritinemia).Hyperferritinemia in elderly inpatients is associated with high rates of mortality. Within this group of patients, differential ferritin levels enable further risk stratification. High ferritin levels in the elderly can differentiate the bad from the worst.
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Affiliation(s)
- Gal Goldhaber
- Department of Internal Medicine “T”, Chaim Sheba Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Hashomer
| | - Gad Segal
- Department of Internal Medicine “T”, Chaim Sheba Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Hashomer
| | - Amir Dagan
- Rheumatology Unit, Assuta Ashdod Medical Center, Affiliated with Ben-Gurion University of the Negev, Ashdod
- Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Hoshomer, Israel
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35
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Khizroeva JH, Makatsariya AD, Bitsadze VO, Tretyakova MV, Slukhanchuk EV, Elalamy I, Gris JC, Radetskaya LS, Makatsariya NA, Sulina YY, Tsibizova VI, Shkoda AS, Blinov DV. Laboratory monitoring of COVID-19 patients and importance of coagulopathy markers. ACTA ACUST UNITED AC 2020. [DOI: 10.17749/2313-7347.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The pandemic of a novel coronavirus infection COVID-19 has become a real challenge to the mankind and medical community and has raised a number of medical and social issues. Based on the currently available information on COVID-19 clinical cases, it follows that COVID-19 patients in critical condition exhibit a clinical picture of disseminated intravascular coagulation (DIC), septic shock with developing multiple organ failure, which justifies use of anticoagulant therapy in COVID-19 patients. In addition to isolating virus RNA from biological material and polymerase chain reaction diagnostics, use of simple and easily accessible laboratory blood markers is necessary for management of COVID-19 patients. If the activation of coagulation processes is sufficient enough, consumption of platelets and blood clotting factors can be diagnosed by laboratory methods as prolongation of routine blood clotting tests and increasing thrombocytopenia. Hyperfibrinogenemia, increased D-dimer level, prolonged prothrombin time, thrombocytopenia, lymphopenia, leukocytopenia, increased concentration of interleukin-6 and ferritin are observed in most COVID19 patients. The degree of increase in these changes correlates with severity of the inflammatory process and serves as a prognostically unfavorable sign. Here we discuss value of laboratory monitoring playing an essential role in such pathological crisis that contributes to patient screening, diagnosis as well as further monitoring, treatment and rehabilitation.
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Affiliation(s)
| | | | | | | | | | - I. Elalamy
- Sechenov University;
Medicine Sorbonne University;
University of Montpellier
| | - J.-C. Gris
- Sechenov University;
Université de Montpellier
| | | | | | | | | | - A. S. Shkoda
- City Clinical Hospital No 67 named after L.A. Vorokhobov
| | - D. V. Blinov
- Institute for Preventive and Social Medicine;
Lapino Clinic Hospital, MD Medical Group;
Moscow Haass Medical – Social Institute
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Urinary ferritin creatinine ratio, a potential biomarker for lupus nephritis activity. Clin Rheumatol 2020; 40:143-149. [PMID: 32557256 DOI: 10.1007/s10067-020-05214-0] [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: 10/14/2019] [Revised: 05/24/2020] [Accepted: 05/29/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION/OBJECTIVE Ferritin has gained increasing attention in systemic lupus erythematosus (SLE).This study aimed to investigate the clinical significance of urinary ferritin/creatinine ratio in lupus nephritis (LN). METHOD Samples from 62 SLE patients (35 with LN and 27 without LN) and 62 healthy controls were evaluated. There were nine patients who underwent renal biopsy. The amount of urinary ferritin was measured by enzyme-linked immunosorbent assay (ELISA) and normalized by the amount of urinary creatinine to obtain the urinary ferritin/creatinine ratio (UFCR). The relationships between UFCR and inflammatory markers, laboratory indicators, as well as the activity index (AI), and chronicity index (CI) of KBs were also investigated by correlation analysis. RESULTS UFCR level in severe active SLE patients was significantly higher than that in inactive SLE patients (P < 0.01) or healthy controls (P < 0.01). In addition, UFCR level was significantly increased in the patients with LN when compared with those without LN (P < 0.01).Correlation analysis showed that UFCR level is positively correlated with Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) (P < 0.01), 24 h urine protein quantitation, serum creatinine, serum cystatin C, and GFR. The UFCR levels was significantly positively correlated with AI (P < 0.05) but not CI (P = 0.614) of KBs. CONCLUSIONS UFCR level is a potential biomarker for the kidney injury in LN. Key Points • UFCR level is significantly increased in LN patients. • UFCR level is positively correlated with SLEDAI. • UFCR level is closely related to kidney injury indicators. • UFCR level is a potential biomarker for the kidney injury in LN.
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Monteagudo LA, Boothby A, Gertner E. Continuous Intravenous Anakinra Infusion to Calm the Cytokine Storm in Macrophage Activation Syndrome. ACR Open Rheumatol 2020; 2:276-282. [PMID: 32267081 PMCID: PMC7231518 DOI: 10.1002/acr2.11135] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The objective of this study was to report the benefit of a therapeutic approach consisting of intravenous (IV) continuous anakinra (recombinant human interleukin-1 receptor antagonist) infusions in treating severely ill adult patients with secondary hemophagocytic lymphohistiocytosis or macrophage activation syndrome (MAS). METHODS A retrospective chart review of five patients treated at Regions Hospital from 2016 to 2019 was conducted. Demographic, clinical, and laboratory characteristics and outcomes were recorded. RESULTS Continuous IV anakinra infusions up to 2400 mg/d resulted in rapid serologic, then clinical response in 4 of 5 severely ill patients who were refractory to all other therapies, including subcutaneous anakinra. Subsequently, 3 of 5 patients have been maintained on anakinra or canakinumab, with no recurrence of MAS. CONCLUSION Continuous infusion of IV anakinra may result in rapid serologic and subsequent clinical improvement in adult patients with MAS. This method for treating cytokine storm should be considered in the current COVID-19 pandemic in the subgroup of patients with severe disease who have a cytokine storm presentation.
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Affiliation(s)
- Luke Adam Monteagudo
- Regions Hospital, HealthPartners, St. Paul, Minnesota, and University of Minnesota Medical School, Minneapolis
| | | | - Elie Gertner
- Regions Hospital, HealthPartners, St. Paul, Minnesota, and University of Minnesota Medical School, Minneapolis
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Gao WB, Shi MJ, Song XJ, Yang J, Zhu JH. [Clinical analysis of 81 adult patients with hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:248-250. [PMID: 32311896 PMCID: PMC7357923 DOI: 10.3760/cma.j.issn.0253-2727.2020.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Indexed: 12/15/2022]
Affiliation(s)
- W B Gao
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - M J Shi
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - X J Song
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - J Yang
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
| | - J H Zhu
- Emergency Department, Peking University People's Hospital, Beijing 100044, China
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A Case of Relapsing Polychondritis Mimicking Hemophagocytic Lymphohistiocytosis After Propionibacterium acnes Infection. J Clin Rheumatol 2020; 25:e75-e77. [PMID: 29280824 DOI: 10.1097/rhu.0000000000000667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Ismail AAA, Ismail A, Ismail Y. Diagnosis of hereditary haemochromatosis. Ann Clin Biochem 2020; 57:192-193. [DOI: 10.1177/0004563219868253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Abbas Ismail
- Stockport NHS Trust, Poplar Grove, Stockport, UK
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41
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Naymagon L, Tremblay D, Mascarenhas J. Reevaluating the role of ferritin in the diagnosis of adult secondary hemophagocytic lymphohistiocytosis. Eur J Haematol 2020; 104:344-351. [PMID: 31991015 DOI: 10.1111/ejh.13391] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The standard diagnostic criteria for hemophagocytic lymphohistiocytosis (HLH) include hyperferritinemia to >500 ng/mL. This ferritin threshold is based on pediatric data, and evidence for its application among adults with secondary HLH is lacking. OBJECTIVE AND METHODS We conducted a retrospective study assessing the relationship between extreme hyperferritinemia and adult secondary HLH at our institution. All adult inpatients seen over a 10-year period, with serum ferritin >5000 ng/mL, were included. RESULTS Among 1055 patients with serum ferritin >5000 ng/mL, there were 69 cases of HLH (HLH prevalence of 6.5%). Mean ferritin among HLH patients was 70 398 ng/mL (SD 122 908), median 40 019 ng/mL (IQR 16 051-68 326). The prevalence of HLH only reached 50% as serum ferritin approached 90 000 ng/mL. A variety of conditions were contributory to hyperferritinemia, most commonly bacterial sepsis (33%), hematologic malignancy (29%), renal failure (24%), and liver injury (18%). The optimal cutoff ferritin for diagnosis of HLH was 16 000 ng/mL (sensitivity 79.4%, specificity 79.2%, PPV 20.9%, and NPV 98.2%). CONCLUSIONS The threshold ferritin levels used in diagnostic criteria for adult secondary HLH are too low to be clinically relevant, and efforts should be undertaken to revise them upward. Similar reappraisals should be taken of the other criteria used to diagnose adult HLH.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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von Bahr Greenwood T, Palmkvist-Kaijser K, Chiang SC, Tesi B, Bryceson YT, Hjelmqvist H, Henter JI. Elevated ferritin and soluble CD25 in critically ill patients are associated with parameters of (hyper) inflammation and lymphocyte cytotoxicity. Minerva Anestesiol 2019; 85:1289-1298. [DOI: 10.23736/s0375-9393.19.13534-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Mamur S, Yuzbasioglu D, Altok K, Unal F, Deger SM. Determination of genotoxic effects in hemodialysis patients with chronic kidney disease and the role of diabetes mellitus and other biochemical parameters. MUTATION RESEARCH-GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2019; 844:46-53. [DOI: 10.1016/j.mrgentox.2019.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/19/2019] [Accepted: 05/29/2019] [Indexed: 02/04/2023]
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Sungkar T, Rozi MF, Dairi LB, Zain LH. Serum Ferritin Levels: A Potential Biomarker to Represent Child-Turcotte-Pugh Score among Decompensated Liver Cirrhosis Patients. Malays J Med Sci 2019; 26:59-65. [PMID: 31447609 PMCID: PMC6687222 DOI: 10.21315/mjms2019.26.2.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/04/2019] [Indexed: 01/05/2023] Open
Abstract
Background Liver cirrhosis and the child-Turcotte-Pugh (CTP) score are inseparable entities in liver disease. CTP score is largely known as the mortality and prognosis predictor. Nevertheless, ferritin emerges as a simple biomarker related to prognosis. The study aimed to determine whether there was a significant correlation between serum ferritin levels and CTP score. Methods The study analysed 54 decompensated liver cirrhotic patients including 17 females and 37 males between May 2016 and May 2017 at the Haji Adam Malik General Hospital, Medan, Indonesia. Ferritin levels were, then, divided into trichotomous cut-off value (< 200 ng/mL, n = 22; 200–400 ng/mL, n = 5; and > 400 ng/mL, n = 27). Data was analysed using SPSS version 12.0 (continuous variables were assessed by the Kruskal-Wallis test and Chi-square test was used for categorical variables). In addition, Spearman correlation test was used to determine any significant correlation between ferritin levels and CTP score. Results Based on data analysis, gender and CTP score were related to higher ferritin levels (P = 0.002 and P = 0.018, respectively). Furthermore, a significant correlation between serum ferritin levels and CTP score was obtained in to moderate degree (P = 0.000; r = 0.487). Conclusions There might be a significant role of serum ferritin levels in predicting mortality and prognosis among decompensated liver cirrhosis patients but it still needs further attention.
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Affiliation(s)
- Taufik Sungkar
- Department of Internal Medicine, Gastroenterology-Hepatology Division, Universitas Sumatera Utara, Padang Bulan, Medan, Indonesia
| | | | - Leo Basa Dairi
- Department of Internal Medicine, Gastroenterology-Hepatology Division, Universitas Sumatera Utara, Padang Bulan, Medan, Indonesia
| | - Lukman Hakim Zain
- Department of Internal Medicine, Gastroenterology-Hepatology Division, Universitas Sumatera Utara, Padang Bulan, Medan, Indonesia
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Walkty A, Karlowsky J, Zarychanski R, Kadkhoda K, Lagacé-Wiens P. Marked elevation of serum ferritin associated with Anaplasma phagocytophilum infection. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2019; 4:37-41. [PMID: 36338785 PMCID: PMC9603192 DOI: 10.3138/jammi.2018-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/07/2018] [Indexed: 06/16/2023]
Abstract
Human granulocytic anaplasmosis (HGA) is a tick-borne disease caused by the intracellular bacterial pathogen Anaplasma phagocytophilum. Patients typically present with non-specific symptoms, including high fever, headache, malaise, and myalgias. Laboratory investigations often reveal leukopenia, thrombocytopenia, and an elevation in serum hepatic aminotransferases. A marked elevation in ferritin with or without other features of hemophagocytic/macrophage activation syndrome has been occasionally reported in patients with A. phagocytophilum infection. A case of HGA is described in which the patient had an elevated ferritin of 1964 μg/L. For patients presenting with features of hemophagocytic syndrome including a markedly elevated ferritin, infection with A. phagocytophilum should be considered in the differential diagnosis in the appropriate clinical context (i.e., at-risk geographic location, season, tick exposure) as this distinction has management implications.
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Affiliation(s)
- Andrew Walkty
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Shared Health, Winnipeg, Manitoba, Canada
| | - James Karlowsky
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Shared Health, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Sections of Haematology and Medical Oncology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kamran Kadkhoda
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Cadham Provincial Laboratory, Winnipeg, Manitoba, Canada
- Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Philippe Lagacé-Wiens
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Shared Health, Winnipeg, Manitoba, Canada
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46
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Stroud J. A mechanistic theory explaining hyperferritinaemia in haemophagocytic lymphohistiocytosis. Med Hypotheses 2019; 122:165-171. [DOI: 10.1016/j.mehy.2018.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 12/26/2022]
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47
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Nishiwaki H, Fukuma S, Hasegawa T, Kimachi M, Akizawa T, Fukuhara S. Dialysis-related practice patterns among hemodialysis patients with cancer. Health Sci Rep 2018; 1:e46. [PMID: 30623084 PMCID: PMC6266572 DOI: 10.1002/hsr2.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/11/2018] [Accepted: 04/05/2018] [Indexed: 01/06/2023] Open
Abstract
RATIONALE AIMS AND OBJECTIVES With the achievement of longevity in hemodialysis patients, the risk of comorbid cancer has begun to draw attention. In the present study, we examined dialysis-related practice patterns and compared those patterns by cancer status. METHODS Using data from the Japan Dialysis Outcomes and Practice Patterns Study phase 4, we evaluated 2153 hemodialysis patients. Baseline cancer status for patients was separated into 3 categories: no cancer, cancer with recent treatment, and cancer without recent treatment. We then assessed variations among hemodialysis patients in dialysis-related practice patterns, including anemia management, management of mineral and bone metabolism disorder, nutritional management, and dialysis treatment, by cancer status. RESULTS We observed both similarities and differences in dialysis-related practice patterns among hemodialysis patients, by cancer status. Hemoglobin levels were largely similar for all cancer statuses, although erythropoiesis stimulating agents dose tended to be higher in hemodialysis patients with recent cancer treatment (multivariable adjusted mean difference of erythropoiesis stimulating agents dose: 5.4 × 103 IU/L/month) than in those without cancer. Phosphorus and calcium levels were also similar. Nutrition statuses were similar among cancer statuses, as were dialysis therapies. These results suggested that physicians do not modulate their dialysis-related practices based on whether or not a hemodialysis patient has cancer. CONCLUSION Among long-term facility-based hemodialysis patients with cancer, we detected no statistically significant differences to suggest that cancer status affects hemodialysis practice regarding mineral and bone disorder management, nutritional management, and dialysis treatment. Facility-based hemodialysis patients with recent cancer treatment, however, receive a higher dose of erythropoietin-stimulating agent than those without cancer.
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Affiliation(s)
- Hiroki Nishiwaki
- Center for Innovative Research for Communities and Clinical ExcellenceFukushima Medical UniversityFukushimaJapan
- Division of Nephrology, Department of Internal MedicineShowa University Fujigaoka HospitalYokohamaJapan
| | - Shingo Fukuma
- Center for Innovative Research for Communities and Clinical ExcellenceFukushima Medical UniversityFukushimaJapan
- Human Health SciencesKyoto University Graduate School of MedicineKyotoJapan
- Institute for Health Outcomes and Process Evaluation Research (iHope International)KyotoJapan
| | - Takeshi Hasegawa
- Center for Innovative Research for Communities and Clinical ExcellenceFukushima Medical UniversityFukushimaJapan
- Division of Nephrology, Department of Internal MedicineShowa University Fujigaoka HospitalYokohamaJapan
- Institute for Health Outcomes and Process Evaluation Research (iHope International)KyotoJapan
- Office for Promoting Medical ResearchShowa UniversityTokyoJapan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Miho Kimachi
- Institute for Health Outcomes and Process Evaluation Research (iHope International)KyotoJapan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Tadao Akizawa
- Division of Nephrology, Department of MedicineShowa University School of MedicineTokyoJapan
| | - Shunichi Fukuhara
- Center for Innovative Research for Communities and Clinical ExcellenceFukushima Medical UniversityFukushimaJapan
- Institute for Health Outcomes and Process Evaluation Research (iHope International)KyotoJapan
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Prognostic Factors and Outcomes in Adults With Secondary Hemophagocytic Lymphohistiocytosis: A Single-center Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:e373-e380. [PMID: 30037588 DOI: 10.1016/j.clml.2018.06.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/31/2018] [Accepted: 06/11/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a disorder caused by severe immune activation. There are no specific criteria to establish the diagnosis in adults; however, the HLH-04 criteria are among the most commonly used. The HScore is a non-validated tool that can also be useful for HLH diagnosis. PATIENTS AND METHODS We describe the prognostic factors and outcomes of 64 adults diagnosed with HLH in a reference medical center in Mexico City. We included patients ≥ 18 years with HLH, diagnosed and treated at our institution from 1998 to 2016. RESULTS The median age was 35 years (range, 18-77 years). The underlying cause of HLH was lymphoma in 33 (51.56%) patients (MA-HLH). Cutaneous involvement was more frequent in MA-HLH (33.33%), when compared with patients with non-malignancy associated HLH (NM-HLH) (9.68%) (P = .022). Neurologic symptoms were more frequent in NM-HLH (25.81%) versus MA-HLH (6.06%) (P = .032). After a median follow-up of 14 months (range, 0-216 months), 30-day mortality was 26.56%. Three-year overall survival (OS) was higher for patients with MA-HLH compared with patients with NM-HLH (41% vs. 22.5%; P = .046). Multivariate analysis showed that the presence of nosocomial infection and neurologic symptoms were statistically significant predictors of inferior OS (P = .034 and P = .033, respectively). CONCLUSION In this series of adults with HLH, patients with nosocomial infections and neurologic symptoms had a statistically significant worse OS. In the largest series in Latin America, the most common cause of HLH was T-cell lymphoma. In our population, NM-HLH presented a higher mortality.
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Senjo H, Higuchi T, Okada S, Takahashi O. Hyperferritinemia: causes and significance in a general hospital. Hematology 2018; 23:817-822. [DOI: 10.1080/10245332.2018.1488569] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Hajime Senjo
- Internal Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Takakazu Higuchi
- Division of Hematology, St. Luke’s International Hospital, Tokyo, Japan
| | - Sadamu Okada
- Division of Hematology, St. Luke’s International Hospital, Tokyo, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, St. Luke’s International Hospital, Tokyo, Japan
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50
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Cullis JO, Fitzsimons EJ, Griffiths WJ, Tsochatzis E, Thomas DW. Investigation and management of a raised serum ferritin. Br J Haematol 2018; 181:331-340. [PMID: 29672840 DOI: 10.1111/bjh.15166] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Serum ferritin level is one of the most commonly requested investigations in both primary and secondary care. Whilst low serum ferritin levels invariably indicate reduced iron stores, raised serum ferritin levels can be due to multiple different aetiologies, including iron overload, inflammation, liver or renal disease, malignancy, and the recently described metabolic syndrome. A key test in the further investigation of an unexpected raised serum ferritin is the serum transferrin saturation. This guideline reviews the investigation and management of a raised serum ferritin level. The investigation and management of genetic haemochromatosis is not dealt with however and is the subject of a separate guideline.
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Affiliation(s)
- Jonathan O Cullis
- Department of Haematology, Salisbury NHS Foundation Trust, Salisbury, UK
| | | | - William Jh Griffiths
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emmanouil Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free London NHS Foundation Trust and University College, London, UK
| | - D Wayne Thomas
- Department of Haematology, Plymouth Hospitals NHS Trust, Plymouth, UK
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