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Wang T, liu X, Lin L, Pei R, Lu Y. A novel mutation of LYST and haemophagocytic lymphohistiocytosis as the first symptom in children with ph+ALL: A case report and literature review. Leuk Res Rep 2024; 22:100481. [PMID: 39410968 PMCID: PMC11474221 DOI: 10.1016/j.lrr.2024.100481] [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: 06/04/2024] [Revised: 08/12/2024] [Accepted: 09/20/2024] [Indexed: 10/19/2024] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare disorder. This study sheds light on a rare and intriguing case of HLH as the initial symptom in a child with Philadelphia chromosome-positive acute lymphoblastic leukaemia (ph+ALL). This case report, accompanied by a comprehensive literature review, highlights the diagnostic challenges and treatment complexities encountered in the management of such rare manifestations. Moreover, the identification of a novel mutation in the LYST gene adds a unique genetic perspective to the understanding of HLH pathogenesis, potentially opening avenues for further research in this area.
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Affiliation(s)
- Tiantian Wang
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, No. 251 Baizhang East Road, Ningbo 315040, China
- Department of Hematology, Ningbo Yinzhou People's Hospital Community, No.251 Baizhang East Road, Ningbo 315040, China
- Institute of Hematology, Ningbo University, No. 818 Fenghua Road, Ningbo 315211, China
| | - Xuhui liu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, No. 251 Baizhang East Road, Ningbo 315040, China
- Department of Hematology, Ningbo Yinzhou People's Hospital Community, No.251 Baizhang East Road, Ningbo 315040, China
- Institute of Hematology, Ningbo University, No. 818 Fenghua Road, Ningbo 315211, China
| | - Li Lin
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, No. 251 Baizhang East Road, Ningbo 315040, China
- Department of Hematology, Ningbo Yinzhou People's Hospital Community, No.251 Baizhang East Road, Ningbo 315040, China
- Institute of Hematology, Ningbo University, No. 818 Fenghua Road, Ningbo 315211, China
| | - Renzhi Pei
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, No. 251 Baizhang East Road, Ningbo 315040, China
- Department of Hematology, Ningbo Yinzhou People's Hospital Community, No.251 Baizhang East Road, Ningbo 315040, China
- Institute of Hematology, Ningbo University, No. 818 Fenghua Road, Ningbo 315211, China
| | - Ying Lu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, No. 251 Baizhang East Road, Ningbo 315040, China
- Department of Hematology, Ningbo Yinzhou People's Hospital Community, No.251 Baizhang East Road, Ningbo 315040, China
- Institute of Hematology, Ningbo University, No. 818 Fenghua Road, Ningbo 315211, China
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2
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Tulling AJ, Holierhoek MG, Jansen-Hoogendijk AM, Hoste L, Haerynck F, Tavernier SJ, Oostenbrink R, Buysse CMP, Bannier MAGE, Bekhof J, Breukels M, Hammer SC, Jacobs MAM, Kamps AWA, van der Linden JW, Lebon A, Oudshoorn JH, Tramper-Stranders GA, Vastert SJ, Wieringa JW, Terheggen-Lagro SWJ, Wildenbeest JG, von Asmuth EGJ, van den Akker EB, van Gijn ME, Lugthart G, Buddingh EP. Serum proteomics reveals hemophagocytic lymphohistiocytosis-like phenotype in a subset of patients with multisystem inflammatory syndrome in children. Clin Immunol 2024; 264:110252. [PMID: 38744408 DOI: 10.1016/j.clim.2024.110252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/10/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
Children with Multisystem Inflammatory Syndrome in Children (MIS-C) can present with thrombocytopenia, which is a key feature of hemophagocytic lymphohistiocytosis (HLH). We hypothesized that thrombocytopenic MIS-C patients have more features of HLH. Clinical characteristics and routine laboratory parameters were collected from 228 MIS-C patients, of whom 85 (37%) were thrombocytopenic. Thrombocytopenic patients had increased ferritin levels; reduced leukocyte subsets; and elevated levels of ASAT and ALAT. Soluble IL-2RA was higher in thrombocytopenic children than in non-thrombocytopenic children. T-cell activation, TNF-alpha and IFN-gamma signaling markers were inversely correlated with thrombocyte levels, consistent with a more pronounced cytokine storm syndrome. Thrombocytopenia was not associated with severity of MIS-C and no pathogenic variants were identified in HLH-related genes. This suggests that thrombocytopenia in MIS-C is not a feature of a more severe disease phenotype, but the consequence of a distinct hyperinflammatory immunopathological process in a subset of children.
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Affiliation(s)
- Adam J Tulling
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Marloes G Holierhoek
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Levi Hoste
- Primary Immunodeficiency Research Lab (PIRL), Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Center for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Filomeen Haerynck
- Primary Immunodeficiency Research Lab (PIRL), Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Center for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Simon J Tavernier
- Primary Immunodeficiency Research Lab (PIRL), Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Center for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Rianne Oostenbrink
- Department of General Pediatrics, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands
| | - Corinne M P Buysse
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Michiel A G E Bannier
- Department of Pediatrics, MosaKids Children's Hospital, University Medical Center Maastricht, Maastricht, the Netherlands
| | - Jolita Bekhof
- Department of Pediatrics, Isala Hospital, Zwolle, the Netherlands
| | - Mijke Breukels
- Department of Pediatrics, Elkerliek Hospital, Helmond, the Netherlands
| | - Sanne C Hammer
- Department of Pediatrics, Amphia Hospital, Breda, the Netherlands
| | - Monique A M Jacobs
- Department of Pediatrics, Slingeland Hospital, Doetinchem, the Netherlands
| | - Arvid W A Kamps
- Department of Pediatrics, Martini Hospital, Groningen, the Netherlands
| | | | - Ankie Lebon
- Department of Pediatrics, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | | | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, the Hague, the Netherlands
| | - Suzanne W J Terheggen-Lagro
- Department of Pediatric Pulmonology and Allergy, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Joanne G Wildenbeest
- Department of Pediatric Infectious Diseases, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik G J von Asmuth
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik B van den Akker
- Leiden Computational Biology Center, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands; The Delft Bioinformatics Lab, Pattern Recognition & Bioinformatics, Delft University of Technology, Delft, the Netherlands
| | - Marielle E van Gijn
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gertjan Lugthart
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Emilie P Buddingh
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands.
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3
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Pešić A, Vuković V, Kozarac S, Otašević V, Bibić T, Mihaljević B, Antić D. Unique presentation of T-cell/histiocyte-rich large B cell lymphoma complicated with hemophagocytic lymphohistiocytosis: Case report and review of the literature. J Med Biochem 2024; 43:631-637. [PMID: 39139166 PMCID: PMC11318850 DOI: 10.5937/jomb0-48290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/23/2023] [Indexed: 08/15/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, lifethreatening hyperinflammatory disorder characterized by dysfunction of NK cells and cytotoxic lymphocytes. We present a rare case of a patient diagnosed with HLH who presented with persistent fever during treatment for refractory T-cell/histiocyte-rich large B-cell lymphoma (TCHRLBCL), highlighting the challenges of managing HLH in the context of refractory lymphoma. According to our review of the literature, this is the first case of HLH that developed several months into treatment for refractory TCHRLBCL and not in close temporal relation to lymphoma diagnosis.
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Affiliation(s)
- Andrej Pešić
- University Clinical Center of Serbia, Clinic for Hematology, Belgrade
| | - Vojin Vuković
- University Clinical Center of Serbia, Clinic for Hematology, Belgrade
| | - Sofija Kozarac
- University Clinical Center of Serbia, Clinic for Hematology, Belgrade
| | - Vladimir Otašević
- University Clinical Center of Serbia, Clinic for Hematology, Belgrade
| | - Tamara Bibić
- University Clinical Center of Serbia, Clinic for Hematology, Belgrade
| | | | - Darko Antić
- University Clinical Center of Serbia, Clinic for Hematology, Belgrade
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4
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Costa E Silva T, Jorge Alves H, Horta Antunes J, Noronha C, Sousa Picado B. Hemophagocytic Lymphohistiocytosis: A Case Report. Cureus 2024; 16:e61015. [PMID: 38910771 PMCID: PMC11194037 DOI: 10.7759/cureus.61015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
The hemophagocytic syndrome (HS) or hemophagocytic lymphohistiocytosis (HLH) is a syndrome with apoptosis deficiency that results in the impairment of a regulatory pathway with consequent immune and inflammatory responses. Fever, cytopenias, splenomegaly, and hemophagocytosis are cardinal signs. It may be familial or secondary to infection, autoimmunity, or neoplasia. Impaired natural killer (NK)-cell cytotoxicity is the hallmark of HLH. All genetic defects in familial HLH are related to granule-dependent cytotoxicity. The authors present a 50-year-old black female patient with a history of drepanocytosis who attended the emergency department due to fever, asthenia, lethargy, and hypogastric pain. Her laboratory workup on admission revealed severe pancytopenia. She was ultimately diagnosed with HLH due to sepsis of urinary origin, with a fatal outcome. HLH is a rare and life-threatening syndrome. The delay in its diagnosis due to the variability of the clinical and laboratory findings constitutes the main obstacle to a successful prognosis, as illustrated in this case report.
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Affiliation(s)
| | | | | | - Carla Noronha
- Internal Medicine, Hospital Beatriz Ângelo, Loures, PRT
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5
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Malavige GN, Ogg GS. Molecular mechanisms in the pathogenesis of dengue infections. Trends Mol Med 2024; 30:484-498. [PMID: 38582622 DOI: 10.1016/j.molmed.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/08/2024]
Abstract
Dengue is the most rapidly emerging climate-sensitive infection, and morbidity/mortality and disease incidence are rising markedly, leading to healthcare systems being overwhelmed. There are currently no specific treatments for dengue or prognostic markers to identify those who will progress to severe disease. Owing to an increase in the burden of illness and a change in epidemiology, many patients experience severe disease. Our limited understanding of the complex mechanisms of disease pathogenesis has significantly hampered the development of safe and effective treatments, vaccines, and biomarkers. We discuss the molecular mechanisms of dengue pathogenesis, the gaps in our knowledge, and recent advances, as well as the most crucial questions to be answered to enable the development of therapeutics, biomarkers, and vaccines.
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Affiliation(s)
- Gathsaurie Neelika Malavige
- Allergy Immunology and Cell Biology Unit, Department of Immunology and Molecular Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka; Medical Research Council (MRC) Translational Immune Discovery Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.
| | - Graham S Ogg
- Allergy Immunology and Cell Biology Unit, Department of Immunology and Molecular Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka; Medical Research Council (MRC) Translational Immune Discovery Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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6
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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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7
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Vasco AE, Talano JA, Broglie L. Hemophagocytic Lymphohistiocytosis in Adolescents and Young Adults: Genetic Predisposition and Secondary Disease. Med Clin North Am 2024; 108:189-200. [PMID: 37951650 DOI: 10.1016/j.mcna.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disorder of impaired immune regulation resulting in hyperinflammation that is ultimately fatal if not treated. HLH is categorized into familial disease, caused by genetic mutations affecting the function of cytotoxic T lymphocytes and natural killer cells, and secondary disease, triggered by infections, malignancies, rheumatologic disorders, or immune deficiency. Adolescent and young adults with HLH represent a unique population with specific diagnostic challenges. Here we review the diagnostic criteria, possible etiologies, pathophysiology, and management of HLH with focus on the adolescent population.
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Affiliation(s)
- Alejandra Escobar Vasco
- Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA; Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA
| | - Julie-Ann Talano
- Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA; Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA
| | - Larisa Broglie
- Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA; Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA.
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8
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Li YQ, Zhang YH, Teng GS, Hu NB, Wang Y, Duan YF, Bai J. [Clinical features of hemophagocytic lymphohistiocytosis associated with myeloid neoplasms: a report of 8 cases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:949-951. [PMID: 38185527 PMCID: PMC10753253 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Y Q Li
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Y H Zhang
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - G S Teng
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - N B Hu
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Y Wang
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Y F Duan
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - J Bai
- Department of Hematology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
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9
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Auerbach A, Aguilera NS. The changing landscape of pediatric histiocytoses: Birth, life, and transdifferentiation of pediatric histiocytes. Semin Diagn Pathol 2023; 40:420-428. [PMID: 37258365 DOI: 10.1053/j.semdp.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/19/2023] [Indexed: 06/02/2023]
Abstract
Histiocytic neoplasms in the children are very rare, and histiocytoses can occur in the perinatal period. The presumed origins and presentation of specific histiocytoses in the pediatric age group are described. Common and newly described histiocytoses are presented including Langerhans cell histiocytosis, Rosai-Dorfman disease, histiocytic sarcoma, ALK positive histiocytosis, and hemophagocytic lymphohistiocytosis. Molecular findings common to pediatric histiocytoses are also discussed.
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Affiliation(s)
- Aaron Auerbach
- Joint Pathology Center, Silver Spring, MD, United States of America
| | - Nadine S Aguilera
- University of Virginia Health System, Charlottesville, VA, United States of America.
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10
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Venigalla T, Kalathil S, Bansal M, Morginstin M, Jorge V, Perosio P. An Unusual Case of Hemophagocytic Lymphohistiocytosis Associated with Mycobacterium chimaera or Large-Cell Neuroendocrine Carcinoma. Curr Oncol 2023; 30:3529-3536. [PMID: 36975481 PMCID: PMC10047052 DOI: 10.3390/curroncol30030268] [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: 02/20/2023] [Revised: 03/16/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and very dangerous condition characterized by abnormal activation of the immune system, causing hemophagocytosis, inflammation, and potentially widespread organ damage. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity, is most commonly seen in children. Secondary HLH is commonly associated with infections, malignancies, and rheumatologic disorders. Most current information on diagnosis and treatment is based on pediatric populations. HLH is a disease that should be diagnosed and treated promptly, otherwise it is fatal. Treatment is directed at treating the triggering disorder, along with symptomatic treatment with dexamethasone and etoposide. We present a 56-year-old patient who was admitted with worsening weakness, exertional dyspnea, dry and nonproductive cough, and a 5-pound weight loss associated with loss of appetite. This is among the rare disorders that are not commonly encountered in day-to-day practice. Our differential diagnoses were broad, including infection, such as visceral leishmaniasis, atypical/tuberculous mycobacteria, histoplasmosis, Ehrlichia, Bartonella, Brucella, Adenovirus, disseminated herpes simplex virus (HSV), hematological-like Langerhans cell histiocytosis, or multicentric Castleman disease; drug reaction, such as drug rash with eosinophilia and systemic symptoms (DRESS); and metabolic disorder, including Wolman's disease (infantile lysosomal acid lipase deficiency) or Gaucher's disease. Based on our investigations as described in our case report, it was narrowed down to hemophagocytic lymphohistiocytosis and COVID-19. Two COVID-19 tests were negative. His lab abnormalities and diagnostic testing revealed hemophagocytic lymphohistiocytosis. He was empirically started on antibiotics and dexamethasone, to be continued for 2 weeks then tapered if the patient showed continued improvement. Dexamethasone was tapered over 8 weeks. He improved on just one of the Food and Drug Administration (FDA)-approved medications, proving that treatment should be tailored to the patient. In addition, in this case study, we included the background, etiology, pathogenesis, diagnosis, management, and prognosis of HLH.
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Affiliation(s)
- Tejaswi Venigalla
- Department of Internal Medicine, Albert Einstein Healthcare Network, East Norriton, PA 19141, USA
| | - Sheila Kalathil
- Department of Hematology-Oncology, Albert Einstein Healthcare Network, Philadelphia, PA 19141, USA
| | - Meena Bansal
- Department of Hematology-Oncology, Albert Einstein Healthcare Network, Philadelphia, PA 19141, USA
| | - Mark Morginstin
- Department of Hematology-Oncology, Albert Einstein Healthcare Network, Philadelphia, PA 19141, USA
| | - Vinicius Jorge
- Department of Hematology-Oncology, Albert Einstein Healthcare Network, Philadelphia, PA 19141, USA
| | - Patricia Perosio
- Department of Pathology, Albert Einstein Healthcare Network, East Norriton, PA 19141, USA
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11
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [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: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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12
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Oygar PD, Gürlevik SL, Sağ E, İlbay S, Aksu T, Demir OO, Coşgun Y, Eyüpoğlu SA, Karakaya J, Cangül ŞÜ, Cengiz AB, Özsürekci Y. Changing Disease Course of Crimean-Congo Hemorrhagic Fever in Children, Turkey. Emerg Infect Dis 2023; 29:268-277. [PMID: 36692327 PMCID: PMC9881758 DOI: 10.3201/eid2902.220976] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Crimean-Congo hemorrhagic fever (CCHF), endemic in certain regions of the world, is listed as a priority disease with pandemic potential. Since CCHF was first identified in Turkey, children have been known to experience milder disease than adults. However, during the COVID-19 pandemic, we observed an unusually severe disease course, including hemophagocytic lymphohistiocytosis (HLH). We examined cytokine/chemokine profiles of 9/12 case-patients compared with healthy controls at 3 time intervals. Interferon pathway-related cytokines/chemokines, including interleukin (IL) 18, macrophage inflammatory protein 3α, and IL-33, were elevated, but tumor necrosis factor-α, IL-6, CXCL8 (formerly IL-8), and cytokines acting through C-C chemokine receptor 2 and CCR5 were lower among case-patients than controls. Interferon pathway activation and cytokines/chemokines acting through CCR2 and CCR5 improved health results among children with severe CCHF. Children can experience severe CCHF, including HLH, and HLH secondary to CCHF can be successfully treated with intravenous immunoglobulin and steroid therapy.
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13
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Stoian M, Procopiescu B, Șeitan S, Scarlat G. Post-COVID-19 syndrome: Insights into a novel post-infectious systemic disorder. J Med Life 2023; 16:195-202. [PMID: 36937488 PMCID: PMC10015558 DOI: 10.25122/jml-2022-0329] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/17/2023] [Indexed: 03/21/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is currently considered a complex systemic infectious and inflammatory disease, determined by the infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the cause of one of the most important epidemiological phenomena in the last century - the COVID-19 pandemic. This infectious-inflammatory disease may generate a wide range of clinical manifestations and biological modifications, explained by the ubiquitous nature of the SARS-CoV-2 receptors, represented by the angiotensin-converting enzyme-2 (ACE-2), and by the host's violent immune and proinflammatory reaction to the viral infection. These manifestations include immunological disturbances, which, according to certain clinical findings, may persist post-infection, in the form of a presumed systemic inflammatory entity, defined by several clinical concepts with a common pathological significance: post-COVID-19 multisystem (or systemic) inflammatory syndrome, post-COVID syndrome or long-COVID. Although the pathophysiological mechanisms of the post-COVID-19 syndrome are elusive at the present moment, there are currently several studies that describe a systemic inflammatory or autoimmune phenomenon following the remission of the COVID-19 infection in some patients, which suggests the existence of molecular and cellular immune abnormalities, most probably due to the host's initial violent immune response to the viral infection, in the form of three overlapping entities: secondary hemophagocytic lymph histiocytosis (HLH), macrophage activation syndrome (MAS) and cytokine release syndrome (CRS). Thus, this is reminiscent of different classic autoimmune diseases, in which various infections are risk factors in developing the autoimmune process.
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Affiliation(s)
- Marilena Stoian
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Corresponding Author: Marilena Stoian, Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. E-mail:
| | - Bianca Procopiescu
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Silviu Șeitan
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Gabriel Scarlat
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
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14
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Kosciejew S, Morris E, Wight J. Coagulopathy is an under-recognised complication of acquired HLH. BMJ Case Rep 2023; 16:e251860. [PMID: 36631166 PMCID: PMC9835868 DOI: 10.1136/bcr-2022-251860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Acquired haemophagocytic lymphohistiocytosis (aHLH) is a rare and often fatal process of uncontrolled cytokine release driven by the inability of natural killer cells to eliminate infected or malignant cells. Herein, we report two cases of aHLH complicated by bleeding secondary to coagulopathy due to hypofibrinogenaemia and thrombocytopenia despite appropriate correction with blood products. These cases highlight the effect coagulopathy and thrombocytopenia can have on patient outcomes when trying to confirm and manage the underlying process driving aHLH.
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Affiliation(s)
- Serena Kosciejew
- Haematology and Bone Marrow Transplant, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Edward Morris
- Haematology and Bone Marrow Transplant, Townsville Hospital and Health Service, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Joel Wight
- Haematology and Bone Marrow Transplant, Townsville Hospital and Health Service, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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15
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Alsohime F, Temsah MH, Alotaibi RM, Alhalabi RM, AlEnezy S, Yousef AA, Alzaydi AM, Inany HS, Al-Eyadhy A, Almazyad M, Alharbi A, Alsoqati AA, Andijani A, Abu Ghazal M, El Masri K, Doussouki M, Butt RF, Alshehri S, Alsatrawi M, Macarambon J, Hasan GM, Alsultan A. Presentations and outcomes of familial hemophagocytic lymphohistiocytosis in the pediatric intensive care units (PICUs). Front Pediatr 2023; 11:1152409. [PMID: 37144147 PMCID: PMC10151775 DOI: 10.3389/fped.2023.1152409] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/30/2023] [Indexed: 05/06/2023] Open
Abstract
Objectives We aimed to describe Familial Hemophagocytic Lymphohistiocytosis (F-HLH) patients' clinical features, intensive care courses, and outcomes. Methods Multi-center retrospective cohort study of pediatric patients diagnosed with F-HLH from 2015 to 2020 in five tertiary centers in Saudi Arabia. Patients were classified as F-HLH based on their genetic confirmation of known mutation or on their clinical criteria, which include a constellation of abnormalities, early disease onset, recurrent HLH in the absence of other causes, or a family history of HLH. Results Fifty-eight patients (28 male, 30 female), with a mean age of 21.0 ± 33.9 months, were included. The most common principal diagnosis was hematological or immune dysfunction (39.7%), followed by cardiovascular dysfunction in 13 (22.4%) patients. Fever was the most common clinical presentation in 27.6%, followed by convulsions (13.8%) and bleeding (13.8%). There were 20 patients (34.5%) who had splenomegaly, and more than 70% of patients had hyperferritinemia >500 mg/dl, hypertriglyceridemia >150 mg/dl and hemophagocytosis in bone marrow biopsy. Compared to deceased patients 18 (31%), survivors had significantly lower PT (p = 041), bilirubin level of <34.2 mmol/L (p = 0.042), higher serum triglyceride level (p = 0.036), and lesser bleeding within the initial 6 h of admission (p = 0.004). Risk factors for mortality included requirements of higher levels of hemodynamic (61.1% vs. 17.5%, p = 0.001) and respiratory (88.9% vs. 37.5%, p < 0.001) support, and positive fungal cultures (p = 0.046). Conclusions Familial HLH still represents a challenge in the pediatric critical care setting. Earlier diagnosis and prompt initiation of appropriate treatment could improve F-HLH survival.
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Affiliation(s)
- Fahad Alsohime
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
- Prince Abdullah bin Khaled Coeliac Disease Research Chair, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Mohamad-Hani Temsah
| | - Rawan M. Alotaibi
- College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Reham M. Alhalabi
- College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Sarah AlEnezy
- College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Aly Abdelrahman Yousef
- Division of Pediatric Critical Care, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Abdullah Mohammed Alzaydi
- Division of Pediatric Critical Care, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hussam Sameer Inany
- Division of Pediatric Critical Care, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ayman Al-Eyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohammed Almazyad
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ali Alharbi
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz Abdullah Alsoqati
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdurahman Andijani
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Abu Ghazal
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Kamal El Masri
- Pediatric Intensive Care Unit, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Maher Doussouki
- Pediatric Hematology & Oncology Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Raheel Farooq Butt
- Pediatric Critical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Saleh Alshehri
- Pediatric Critical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alsatrawi
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Jaramia Macarambon
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Gamal M. Hasan
- Pediatric Department, Assiut Faculty of Medicine, Assiut University, Assiut, Egypt
- Pediatric Department, Pediatric Intensive Care Unit, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Abdulrahman Alsultan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Oncology Center, King Saud University Medical City, Riyadh, Saudi Arabia
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16
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Planas R, Felber M, Vavassori S, Pachlopnik Schmid J. The hyperinflammatory spectrum: from defects in cytotoxicity to cytokine control. Front Immunol 2023; 14:1163316. [PMID: 37187762 PMCID: PMC10175623 DOI: 10.3389/fimmu.2023.1163316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Cytotoxic lymphocytes kill target cells through polarized release of the content of cytotoxic granules towards the target cell. The importance of this cytotoxic pathway in immune regulation is evidenced by the severe and often fatal condition, known as hemophagocytic lymphohistiocytosis (HLH) that occurs in mice and humans with inborn errors of lymphocyte cytotoxic function. The clinical and preclinical data indicate that the damage seen in severe, virally triggered HLH is due to an overwhelming immune system reaction and not the direct effects of the virus per se. The main HLH-disease mechanism, which links impaired cytotoxicity to excessive release of pro-inflammatory cytokines is a prolongation of the synapse time between the cytotoxic effector cell and the target cell, which prompts the former to secrete larger amounts of cytokines (including interferon gamma) that activate macrophages. We and others have identified novel genetic HLH spectrum disorders. In the present update, we position these newly reported molecular causes, including CD48-haploinsufficiency and ZNFX1-deficiency, within the pathogenic pathways that lead to HLH. These genetic defects have consequences on the cellular level on a gradient model ranging from impaired lymphocyte cytotoxicity to intrinsic activation of macrophages and virally infected cells. Altogether, it is clear that target cells and macrophages may play an independent role and are not passive bystanders in the pathogenesis of HLH. Understanding these processes which lead to immune dysregulation may pave the way to novel ideas for medical intervention in HLH and virally triggered hypercytokinemia.
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Affiliation(s)
- Raquel Planas
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
- Department of Cell Biology, Physiology and Immunology, University of Barcelona, Barcelona, Spain
| | - Matthias Felber
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Stefano Vavassori
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Jana Pachlopnik Schmid
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Immunology, University of Zurich, Zurich, Switzerland
- *Correspondence: Jana Pachlopnik Schmid,
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17
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Hemophagocytic Lymphohistiocytosis Associated with Synergistic Defects of AP3B1 and ATM Genes: A Case Report and Literature Review. J Clin Med 2022; 12:jcm12010095. [PMID: 36614895 PMCID: PMC9821123 DOI: 10.3390/jcm12010095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an overwhelming immune system activation that manifests as hyperinflammation and life-threatening multiple organ failure. However, the clinical manifestations of the systemic inflammatory response in sepsis and fulminant cytokine storm caused by HLH macrophage activation are very similar and difficult to distinguish. HLH triggered by two novel gene defects manifesting with multiorgan dysfunction syndrome (MODS) and distributive shock has not been reported. A 14-year-old male patient was hospitalized with a high fever, his condition deteriorated rapidly, accompanied by cytopenia, shock, and MODS, and he was subsequently transferred to our intensive care unit (ICU) for symptomatic and organ-supportive treatments. Laboratory indicators of cytopenia, hypofibrinogenemia, hypertriglyceridemia, hyperferritinemia, high soluble CD25, low natural killer (NK) cell cytotoxicity, and hemophagocytosis in the bone marrow confirmed the diagnosis of HLH. Molecular genetic analysis revealed that two novel heterozygous gene mutations in AP3B1 (c.3197 C > T) and ATM (c.8077 G > T) might have accounted for the onset. After treatment, the patient’s condition successfully improved. This case report demonstrates the timely determination of underlying triggers and critical care supports (supportive and etiological treatment) of HLH related to the improved outcome.
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18
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Muacevic A, Adler JR, Isayed O, Mahagna S, Bseiso A. The Role of Immune Mechanisms, Inflammatory Pathways, and Macrophage Activation Syndrome in the Pathogenesis of Hemophagocytic Lymphohistiocytosis. Cureus 2022; 14:e33175. [PMID: 36726930 PMCID: PMC9885896 DOI: 10.7759/cureus.33175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/01/2023] Open
Abstract
This review article describes the pathophysiology of hemophagocytic lymphohistiocytosis (HLH). The condition is characterized by excessive stimulation of inflammatory cytokines, lymphocytes, and macrophages, leading to hyperinflammatory disorder with immune dysfunction. The main clinical and diagnostic features include fever ≥38.5°C, splenomegaly, hyperferritinemia, cytopenia, hypofibrinogenemia, hemophagocytosis on the bone marrow, low or absent of natural killer (NK) cell activity, and elevated soluble CD25. Various immunological and inflammatory mechanisms are involved in the pathogenesis of HLH. Moreover, the condition can result in multisystem organ failure, contributing to the high mortality rate in hospital settings. A thorough literature search was conducted by collecting data from multiple articles published on PubMed, Medline, and Google Scholar. The article discusses the cellular and molecular pathways that lead to HLH. Due to the high rate of morbidity and mortality, early diagnosis needs to be established. More research pertaining to molecular biology, immunology, and the genetics of HLH is needed to explore the effective management and treatment of this rare disorder.
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19
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He Y, Hui Y, Liu H, Wu Y, Sang H, Liu F. Adult-Onset Familial Hemophagocytic Lymphohistiocytosis Presenting with Annular Erythema following COVID-19 Vaccination. Vaccines (Basel) 2022; 10:vaccines10091436. [PMID: 36146514 PMCID: PMC9501607 DOI: 10.3390/vaccines10091436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis (HLH) is a rare genetic and life-threatening immunodeficiency disease. Here, we present a 38-year-old male who initially developed multiple annular to irregular erythema accompanied by a fever after COVID-19 vaccination. He was diagnosed with HLH with evidence of leukocytopenia in a full blood test, elevations of ferritin and sCD25, decreased NK cell function, and hemophagocytosis of a bone marrow biopsy specimen. A genetic examination revealed two probable disease-causing heterozygous mutations on UNC13D associated with type 3 familial HLH. A review of the case reports relevant to HLH following COVID-19 vaccination and the cutaneous manifestations of HLH with genetic defects suggests the necessity that individuals with preexisting immune dysregulation or diseases not classified should be cautious about COVID-19 vaccination and reminds clinicians that various recalcitrant skin lesions may be a sign of HLH.
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Affiliation(s)
- Yifan He
- Department of Dermatology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Yun Hui
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
| | - Haibo Liu
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
| | - Yifan Wu
- Department of Dermatology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Hong Sang
- Department of Dermatology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
- Correspondence: (H.S.); (F.L.)
| | - Fang Liu
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
- Correspondence: (H.S.); (F.L.)
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20
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Ioannou M, Zacharouli K, Doukas SG, Diamantidis MD, Tsangari V, Karakousis K, Koukoulis GK, Vageli DP. Hemophagocytic lymphohistiocytosis diagnosed by bone marrow trephine biopsy in living post-COVID-19 patients: case report and mini-review. J Mol Histol 2022; 53:753-762. [PMID: 35699822 PMCID: PMC9192937 DOI: 10.1007/s10735-022-10088-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/31/2022] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) constitutes a life-threatening inflammatory syndrome. Postmortem histological findings of bone marrow (BM) from COVID-19 patients showed histiocytosis and hemophagocytosis and supported the hypothesis that secondary HLH (sHLH) may be triggered by SARS-CoV-2 infection. However, there are a limited number of sHLH cases in which trephine has been performed in living post-COVID-19 patients. Here we present a recent case and a mini-review of sHLH diagnosed by trephine biopsy in living patients after COVID-19. An 81-year-old man with a past medical history of hypertension, diabetes, ischemic stroke, was referred to the hospital to evaluate leukocytosis, pyuria, and elevation of inflammatory markers four weeks after recovering from COVID-19. Computed tomography of the abdomen did not reveal focal signs of infection or hepatosplenomegaly. The patient received intravenous meropenem and two packed red blood cell units. Leukocytes and C-reactive protein were gradually decreased. A BM biopsy was performed and the patient was discharged on cefixime. BM smear revealed severe anemia, lymphopenia, and dysplastic morphologic findings of erythroblasts, neutrophils, and megakaryocytes. Trephine biopsy revealed hypercellular marrow dyserythropoiesis, plasmacytosis, lymphocytosis, histiocytosis, hemophagocytosis, and the absence of granulomas or carcinoma. Immunohistochemistry documented a mixed population of T lymphocytes (CD3+) and B lymphocytes (CD20+). Strong positivity for CD68 confirmed histiocytosis. CD138 κ, λ staining proved polyclonal plasmacytosis. Perl's staining showed excess hemosiderin deposits. Based on our findings, we document sHLH in trephine BM biopsy of a living post-COVID-19 patient and persistent leukocytosis, underscoring the diagnostic value of trephine biopsy in preventing life-threatening conditions such as COVID-19.
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Affiliation(s)
- Maria Ioannou
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Konstantina Zacharouli
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Sotirios G Doukas
- Department of Toxicology Department of Forensic Sciences and Laboratory of Toxicology, Medical School, University of Crete, 71003, Heraklion, Greece
- Department of Medicine, Rutgers/Saint Peter's University Hospital, 08901, New Brunswick, NJ, USA
| | - Michael D Diamantidis
- Thalassemia and Sickle Cell Disease Unit, Department of Hematology, General Hospital of Larissa, Larissa, Greece
| | - Vaya Tsangari
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | | | - George K Koukoulis
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Dimitra P Vageli
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece.
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21
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Núñez-Torrón C, Ferrer-Gómez A, Moreno Moreno E, Pérez-Mies B, Villarrubia J, Chamorro S, López-Jiménez J, Palacios J, Piris-Villaespesa M, García-Cosío M. Secondary haemophagocytic lymphohistiocytosis in COVID-19: correlation of the autopsy findings of bone marrow haemophagocytosis with HScore. J Clin Pathol 2022; 75:383-389. [PMID: 33722841 PMCID: PMC7970658 DOI: 10.1136/jclinpath-2020-207337] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/19/2021] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Secondary haemophagocytic lymphohistiocytosis (sHLH) is characterised by a hyper activation of immune system that leads to multiorgan failure. It is suggested that excessive immune response in patients with COVID-19 could mimic this syndrome. Some COVID-19 autopsy studies have revealed the presence of haemophagocytosis images in bone marrow, raising the possibility, along with HScore parameters, of sHLH. AIM Our objective is to ascertain the existence of sHLH in some patients with severe COVID-19. METHODS We report the autopsy histological findings of 16 patients with COVID-19, focusing on the presence of haemophagocytosis in bone marrow, obtained from rib squeeze and integrating these findings with HScore parameters. CD68 immunohistochemical stains were used to highlight histiocytes and haemophagocytic cells. Clinical evolution and laboratory parameters of patients were collected from electronic clinical records. RESULTS Eleven patients (68.7%) displayed moderate histiocytic hyperplasia with haemophagocytosis (HHH) in bone marrow, three patients (18.7%) displayed severe HHH and the remainder were mild. All HScore parameters were collected in 10 patients (62.5%). Among the patients in which all parameters were evaluable, eight patients (80%) had an HScore >169. sHLH was not clinically suspected in any case. CONCLUSIONS Our results support the recommendation of some authors to use the HScore in patients with severe COVID-19 in order to identify those who could benefit from immunosuppressive therapies. The presence of haemophagocytosis in bone marrow tissue, despite not being a specific finding, has proved to be a very useful tool in our study to identify these patients.
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Affiliation(s)
| | | | | | - Belen Pérez-Mies
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Javier López-Jiménez
- Hematology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
| | - J Palacios
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Mónica García-Cosío
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
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22
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Schimke LF, Marques AHC, Baiocchi GC, de Souza Prado CA, Fonseca DLM, Freire PP, Rodrigues Plaça D, Salerno Filgueiras I, Coelho Salgado R, Jansen-Marques G, Rocha Oliveira AE, Peron JPS, Cabral-Miranda G, Barbuto JAM, Camara NOS, Calich VLG, Ochs HD, Condino-Neto A, Overmyer KA, Coon JJ, Balnis J, Jaitovich A, Schulte-Schrepping J, Ulas T, Schultze JL, Nakaya HI, Jurisica I, Cabral-Marques O. Severe COVID-19 Shares a Common Neutrophil Activation Signature with Other Acute Inflammatory States. Cells 2022; 11:cells11050847. [PMID: 35269470 PMCID: PMC8909161 DOI: 10.3390/cells11050847] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/06/2023] Open
Abstract
Severe COVID-19 patients present a clinical and laboratory overlap with other hyperinflammatory conditions such as hemophagocytic lymphohistiocytosis (HLH). However, the underlying mechanisms of these conditions remain to be explored. Here, we investigated the transcriptome of 1596 individuals, including patients with COVID-19 in comparison to healthy controls, other acute inflammatory states (HLH, multisystem inflammatory syndrome in children [MIS-C], Kawasaki disease [KD]), and different respiratory infections (seasonal coronavirus, influenza, bacterial pneumonia). We observed that COVID-19 and HLH share immunological pathways (cytokine/chemokine signaling and neutrophil-mediated immune responses), including gene signatures that stratify COVID-19 patients admitted to the intensive care unit (ICU) and COVID-19_nonICU patients. Of note, among the common differentially expressed genes (DEG), there is a cluster of neutrophil-associated genes that reflects a generalized hyperinflammatory state since it is also dysregulated in patients with KD and bacterial pneumonia. These genes are dysregulated at the protein level across several COVID-19 studies and form an interconnected network with differentially expressed plasma proteins that point to neutrophil hyperactivation in COVID-19 patients admitted to the intensive care unit. scRNAseq analysis indicated that these genes are specifically upregulated across different leukocyte populations, including lymphocyte subsets and immature neutrophils. Artificial intelligence modeling confirmed the strong association of these genes with COVID-19 severity. Thus, our work indicates putative therapeutic pathways for intervention.
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Affiliation(s)
- Lena F. Schimke
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
- Correspondence: (L.F.S.); (O.C.-M.); Tel.: +55-11-943661555 (L.F.S.); +55-11-974642022 (O.C.-M.)
| | - Alexandre H. C. Marques
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Gabriela Crispim Baiocchi
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Caroline Aliane de Souza Prado
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.A.d.S.P.); (D.L.M.F.); (D.R.P.); (A.E.R.O.); (H.I.N.)
| | - Dennyson Leandro M. Fonseca
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.A.d.S.P.); (D.L.M.F.); (D.R.P.); (A.E.R.O.); (H.I.N.)
| | - Paula Paccielli Freire
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Desirée Rodrigues Plaça
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.A.d.S.P.); (D.L.M.F.); (D.R.P.); (A.E.R.O.); (H.I.N.)
| | - Igor Salerno Filgueiras
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Ranieri Coelho Salgado
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Gabriel Jansen-Marques
- Information Systems, School of Arts, Sciences and Humanities, University of Sao Paulo, São Paulo 03828-000, Brazil;
| | - Antonio Edson Rocha Oliveira
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.A.d.S.P.); (D.L.M.F.); (D.R.P.); (A.E.R.O.); (H.I.N.)
| | - Jean Pierre Schatzmann Peron
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Gustavo Cabral-Miranda
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - José Alexandre Marzagão Barbuto
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
- Laboratory of Medical Investigation in Pathogenesis, Targeted Therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Niels Olsen Saraiva Camara
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Vera Lúcia Garcia Calich
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Hans D. Ochs
- Department of Pediatrics, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA 98101, USA;
| | - Antonio Condino-Neto
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
| | - Katherine A. Overmyer
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; (K.A.O.); (J.J.C.)
- Morgridge Institute for Research, Madison, WI 53562, USA
| | - Joshua J. Coon
- National Center for Quantitative Biology of Complex Systems, Madison, WI 53562, USA; (K.A.O.); (J.J.C.)
- Morgridge Institute for Research, Madison, WI 53562, USA
- Department of Biomolecular Chemistry, University of Wisconsin, Madison, WI 53506, USA
- Department of Chemistry, University of Wisconsin, Madison, WI 53506, USA
| | - Joseph Balnis
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA; (J.B.); (A.J.)
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | - Ariel Jaitovich
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA; (J.B.); (A.J.)
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | - Jonas Schulte-Schrepping
- Life and Medical Sciences (LIMES) Institute, University of Bonn, 53115 Bonn, Germany; (J.S.-S.); (J.L.S.)
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), University of Bonn, 53127 Bonn, Germany;
| | - Thomas Ulas
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), University of Bonn, 53127 Bonn, Germany;
- German Center for Neurodegenerative Diseases (DZNE), PRECISE Platform for Genomics and Epigenomics at DZNE, University of Bonn, 53127 Bonn, Germany
| | - Joachim L. Schultze
- Life and Medical Sciences (LIMES) Institute, University of Bonn, 53115 Bonn, Germany; (J.S.-S.); (J.L.S.)
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), University of Bonn, 53127 Bonn, Germany;
- German Center for Neurodegenerative Diseases (DZNE), PRECISE Platform for Genomics and Epigenomics at DZNE, University of Bonn, 53127 Bonn, Germany
| | - Helder I. Nakaya
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.A.d.S.P.); (D.L.M.F.); (D.R.P.); (A.E.R.O.); (H.I.N.)
- Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
- Scientific Platform Pasteur, University of São Paulo, São Paulo 05508-020, Brazil
| | - Igor Jurisica
- Osteoarthritis Research Program, Division of Orthopedic Surgery, Schroeder Arthritis Institute and Data Science Discovery Centre for Chronic Diseases, Krembil Research Institute, University Health Network, Toronto, ON M5T 0S8, Canada;
- Departments of Medical Biophysics and Computer Science, Faculty of Dentistry, University of Toronto, Toronto, ON M5G 1L7, Canada
- Institute of Neuroimmunology, Slovak Academy of Sciences, 845 10 Bratislava, Slovakia
| | - Otávio Cabral-Marques
- Department of Imunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (A.H.C.M.); (G.C.B.); (P.P.F.); (I.S.F.); (R.C.S.); (J.P.S.P.); (G.C.-M.); (J.A.M.B.); (N.O.S.C.); (V.L.G.C.); (A.C.-N.)
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.A.d.S.P.); (D.L.M.F.); (D.R.P.); (A.E.R.O.); (H.I.N.)
- Network of Immunity in Infection, Malignancy, Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), São Paulo 05508-000, Brazil
- Correspondence: (L.F.S.); (O.C.-M.); Tel.: +55-11-943661555 (L.F.S.); +55-11-974642022 (O.C.-M.)
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Wagoner M, Saliba C, Melkonian V, Miyata M, Blewett C, Greenspon J. A rare case of cytomegalovirus-induced hepatitis presenting in a pediatric patient as a hepatic mass. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Severely impaired CTL killing is a feature of the neurological disorder Niemann-Pick Syndrome type C1. Blood 2022; 139:1833-1849. [PMID: 35081253 DOI: 10.1182/blood.2021013477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/18/2022] [Indexed: 11/20/2022] Open
Abstract
Niemann-Pick disease type C1 (NP-C1) is a rare lysosomal storage disorder resulting from mutations in an endo-lysosomal cholesterol transporter, NPC1. Despite typically presenting with pronounced neurological manifestations, NP-C1 also resembles long-term congenital immunodeficiencies that arise due to impairment of cytotoxic T lymphocyte (CTL) effector function. CTLs kill their targets through exocytosis of the contents of lysosome-like secretory cytotoxic granules (CGs) that store, and ultimately release the essential pore-forming protein perforin and pro-apoptotic serine proteases, granzymes, into the synapse formed between the CTL and a target cell. We have discovered that NPC1 deficiency increases CG lipid burden, impairs autophagic flux due to stalled trafficking of the transcription factor EB (TFEB), and dramatically reduces CTL cytotoxicity. Using a variety of immunological and cell biology techniques, we show that the cytotoxic defect arises specifically due to impaired perforin pore-formation. We demonstrated defects of CTL function of varying severity in NP-C1 patients, with the greatest loss of function associated with the most florid and/or earliest disease presentations. Remarkably, perforin function and CTL cytotoxicity were restored in vitro by promoting lipid clearance with therapeutic 2-hydroxypropyl-b-cyclodextrin (HPbCD), whereas restoring autophagy through TFEB over-expression was ineffective. Overall, our study revealed that NPC1 deficiency has a deleterious impact on CTL (but not natural killer cell) cytotoxicity that, in the long term, may predispose NP-C1 patients to atypical infections and impaired immune surveillance more generally.
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25
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Zhou YH, Han XR, Xia FQ, Poonit ND, Liu L. Clinical Features and Prognostic Factors of Early Outcome in Pediatric Hemophagocytic Lymphohistiocytosis: A Retrospective Analysis of 227 Cases. J Pediatr Hematol Oncol 2022; 44:e217-e222. [PMID: 34986134 PMCID: PMC8728756 DOI: 10.1097/mph.0000000000002283] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening clinical syndrome in children, and the knowledge of it is still limited. Two hundred twenty-seven children with HLH in our hospital were retrospectively analyzed from January 2001 to December 2018. The age of the patients on admission ranged from 1 day to 14 years old. The 3 most common clinical manifestations include fever (98.7%), hepatomegaly (95.6%), and splenomegaly (92.1%). The decrease of high-density lipoprotein cholesterol (99.1%) is very common in children with HLH. Albumin<25 g/L, activated partial thromboplastin time >65 s, and lactose dehydrogenase >1000 U/L were independent risk factors for poor early prognosis in children with HLH, and their odds ratio values were 2.515, 3.094, and 2.378, respectively, while age >28 months was identified as a protective factor (odds ratio=0.295). Of the 227 children, 67 (29.52%) died within 30 days of onset. The mortality rate in 2013 to 2018 was significantly lower than that in 2001 to 2012 (16.35% vs. 40.65%, P=0.000). The shortening of the time from onset to admission and the reduction of time from admission to definite diagnosis could be some of the reasons for the decrease of HLH mortality in 2013 to 2018 (P<0.05, respectively). Our study suggests that early identification of risk factors for HLH, timely diagnosis and treatment are important measures to improve the short-term prognosis of HLH in children.
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Affiliation(s)
- Yong-Hai Zhou
- Department of Neonatology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xin-Ru Han
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fang-Qing Xia
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Neha-Devi Poonit
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Li Liu
- Department of Neonatology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an
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26
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Rocco JM, Mallarino-Haeger C, Randolph AH, Ray SM, Schechter MC, Zerbe CS, Holland SM, Sereti I. Hyperinflammatory Syndromes After Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Messenger RNA vaccination in Individuals With Underlying Immune Dysregulation. Clin Infect Dis 2021; 75:e912-e915. [PMID: 34893818 PMCID: PMC8689836 DOI: 10.1093/cid/ciab1024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Indexed: 01/19/2023] Open
Abstract
The development of effective severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) messenger RNA (mRNA) vaccines has been a significant accomplishment. Adverse events are extremely rare, but continued surveillance is important, especially in at-risk populations. In 5 patients with preexisting immune dysregulation, hyperinflammatory syndromes, including hemophagocytic lymphohistiocytosis, developed after SARS-CoV-2 mRNA vaccination. Early recognition of this rare condition is essential.
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Affiliation(s)
- Joseph M Rocco
- Correspondence: Joseph M. Rocco, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bldg 10, Room 11B17, MSC 1876, 10 Center Dr, Bethesda, MD 20892 ()
| | | | - Attiya H Randolph
- Department of Medicine, George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - Susan M Ray
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos C Schechter
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christa S Zerbe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven M Holland
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Munshi A, Alsuraihi A, Balubaid M, Althobaiti M, Althaqafi A. Dengue-Induced Hemophagocytic Lymphohistiocytosis: A Case Report and Literature Review. Cureus 2021; 13:e20172. [PMID: 35003998 PMCID: PMC8724679 DOI: 10.7759/cureus.20172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon fatal disease of otherwise normal but hyperactive lymphocytes and histocytes. HLH could be primary (hereditary) or secondary (acquired). Fever, hepatosplenomegaly, lymphadenopathy, and neurologic dysfunction are among the common symptoms of HLH. The diagnosis of HLH is based on clinical and biochemical findings. We report here a case of a patient infected with the dengue virus who developed HLH during hospitalization. A 63-year-old female known case of asthma on inhalers, chronic hepatitis B virus, gastritis on proton pump inhibitors, and hemoglobin H disease presented to the emergency department (ED) with a history of high-grade fever (highest recorded temperature 40° C/ 104° F), which was relieved partially by antipyretics, generalized fatigability, body aches, headache and mosquito bites for four days. The physical examination was significant for hepatomegaly of 4 cm below the right costal margin. Investigations revealed pancytopenia with elevated ferritin levels (> 40000 µg/L). Viral serology was positive for dengue NS1 antigen. After hematology consultation, a bone marrow biopsy was done, which showed trilineage hematopoiesis with increased histiocytes and occasional hemophagocytosis. Given that the patient was clinically stable and there was a clear triggering condition, we opted for supportive measures rather than HLH-specific therapy. The patient was given 2 units packed red blood cells for anemia. On the following days, the patient has no recurrence of fever, with marked improvement in the biochemical profile including ferritin level (1165 µg/L). HLH is a deleterious disease with a high fatality rate, which requires the clinician to have a low threshold for suspicion in the differentials of children and adults with symptoms of persistent fever, hepatosplenomegaly, and cytopenia. Dengue-associated HLH diagnosis is challenging, but it is very important to be recognized, as early recognition is associated with better outcomes. Physicians must work in collaboration with pathologists and microbiologists for the proper diagnosis.
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Harada T, Tsuboi I, Hino H, Yuda M, Hirabayashi Y, Hirai S, Aizawa S. Age-related exacerbation of hematopoietic organ damage induced by systemic hyper-inflammation in senescence-accelerated mice. Sci Rep 2021; 11:23250. [PMID: 34853370 PMCID: PMC8636590 DOI: 10.1038/s41598-021-02621-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening systemic hyper-inflammatory disorder. The mortality of HLH is higher in the elderly than in young adults. Senescence-accelerated mice (SAMP1/TA-1) exhibit characteristic accelerated aging after 30 weeks of age, and HLH-like features, including hematopoietic organ damage, are seen after lipopolysaccharide (LPS) treatment. Thus, SAMP1/TA-1 is a useful model of hematological pathophysiology in the elderly with HLH. In this study, dosing of SAMP1/TA-1 mice with LPS revealed that the suppression of myelopoiesis and B-lymphopoiesis was more severe in aged mice than in young mice. The bone marrow (BM) expression of genes encoding positive regulators of myelopoiesis (G-CSF, GM-CSF, and IL-6) and of those encoding negative regulators of B cell lymphopoiesis (TNF-α) increased in both groups, while the expression of genes encoding positive-regulators of B cell lymphopoiesis (IL-7, SDF-1, and SCF) decreased. The expression of the GM-CSF-encoding transcript was lower in aged mice than in young animals. The production of GM-CSF by cultured stromal cells after LPS treatment was also lower in aged mice than in young mice. The accumulation of the TNF-α-encoding transcript and the depletion of the IL-7-encoding transcript were prolonged in aged mice compared to young animals. LPS dosing led to a prolonged increase in the proportion of BM M1 macrophages in aged mice compared to young animals. The expression of the gene encoding p16INK4a and the proportion of β-galactosidase- and phosphorylated ribosomal protein S6-positive cells were increased in cultured stromal cells from aged mice compared to those from young animals, while the proportion of Ki67-positive cells was decreased in stromal cells from aged mice. Thus, age-related deterioration of stromal cells probably causes the suppression of hematopoiesis in aged mice. This age-related latent organ dysfunction may be exacerbated in elderly people with HLH, resulting in poor prognosis.
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Affiliation(s)
- Tomonori Harada
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Isao Tsuboi
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hirotsugu Hino
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Miyuki Yuda
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yoko Hirabayashi
- Center for Biological Safety and Research, National Institute of Health Sciences, Kawasaki, 210-9501, Japan
| | - Shuichi Hirai
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shin Aizawa
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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A Young Boy With Hemophagocytic Lymphohistiocytosis Presenting With Vaccine-Related Granulomatous Dermatitis: A Case Report and Literature Review. Am J Dermatopathol 2021; 43:e267-e272. [PMID: 34797807 DOI: 10.1097/dad.0000000000002075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Cutaneous eruptions associated with hemophagocytic lymphohistiocytosis (HLH) have been reported in 6%-63% of patients. Clinical findings of these skin lesions vary widely and include maculopapular rashes, ulcers, and violaceous nodules. Corresponding histologic findings are also variable and are considered nonspecific. We report the case of a 4-year-old boy who initially developed a widespread popular-pustular rash 2 weeks after his 12-month measles, mumps, and rubella vaccinations. These resolved with scarring then recurred following his 24-month vaccinations. Multiple skin biopsies were negative for infectious organisms and showed a granulomatous infiltrate with perforation and necrobiosis. The differential diagnosis included perforating granuloma annulare, infection, or rheumatoid nodules. At the age of 4, he developed fever, hepatosplenomegaly, pancytopenia and other laboratory abnormalities, requiring hospitalization. A number of studies were performed including biopsies of bone marrow and liver. Molecular testing revealed 2 mutations in UNC13D known to be associated with familial HLH. His prior cutaneous lesions were likely caused by immune dysregulation exacerbated by immunizations because of underlying familial HLH. This case illustrates the importance of recognizing an unusual cutaneous manifestation of a rare disease to arrive at an earlier diagnosis in a pediatric patient. Although cutaneous eruptions usually develop concurrently with other systemic symptoms of HLH, preceding unusual skin lesions may be the first indication of this rare disease.
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Tiyo BT, Schmitz GJH, Ortega MM, da Silva LT, de Almeida A, Oshiro TM, Duarte AJDS. What Happens to the Immune System after Vaccination or Recovery from COVID-19? Life (Basel) 2021; 11:1152. [PMID: 34833028 PMCID: PMC8619084 DOI: 10.3390/life11111152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/17/2022] Open
Abstract
Due to its leading role in fighting infections, the human immune system has been the focus of many studies in the context of Coronavirus disease 2019 (COVID-19). In a worldwide effort, the scientific community has transitioned from reporting about the effects of the novel coronavirus on the human body in the early days of the pandemic to exploring the body's many immunopathological and immunoprotecting properties that have improved disease treatment and enabled the development of vaccines. The aim of this review is to explain what happens to the immune system after recovery from COVID-19 and/or vaccination against SARS-CoV-2, the virus that causes the disease. We detail the way in which the immune system responds to a SARS-CoV-2 infection, including innate and adaptive measures. Then, we describe the role of vaccination, the main types of COVID-19 vaccines and how they protect us. Further, we explain the reason why immunity after COVID-19 infection plus a vaccination appears to induce a stronger response compared with virus exposure alone. Additionally, this review reports some correlates of protection from SARS-CoV-2 infection. In conclusion, we reinforce that vaccination is safe and important in achieving herd immunity.
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Matsuo Y, Iwanami K, Hiraoka E, Oda R. Spontaneous Recovery of Hemophagocytic Lymphohistiocytosis Due to Primary Epstein-Barr Virus Infection in an Adult Patient. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933272. [PMID: 34657119 PMCID: PMC8532072 DOI: 10.12659/ajcr.933272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Patient: Male, 34-year-old
Final Diagnosis: Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis
Symptoms: Fever • rash
Medication: —
Clinical Procedure: —
Specialty: Hematology • Immunology • Infectious Diseases
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Affiliation(s)
- Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Keiichi Iwanami
- Department of Rheumatology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Rentaro Oda
- Department of Infectious Diseases, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
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32
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Sharma HN, Latimore COD, Matthews QL. Biology and Pathogenesis of SARS-CoV-2: Understandings for Therapeutic Developments against COVID-19. Pathogens 2021; 10:1218. [PMID: 34578250 PMCID: PMC8470303 DOI: 10.3390/pathogens10091218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/10/2021] [Accepted: 09/15/2021] [Indexed: 01/18/2023] Open
Abstract
Coronaviruses are positive sense, single-stranded, enveloped, and non-segmented RNA viruses that belong to the Coronaviridae family within the order Nidovirales and suborder Coronavirinae. Two Alphacoronavirus strains: HCoV-229E and HCoV-NL63 and five Betacoronaviruses: HCoV-HKU1, HCoV-OC43, SARS-CoV, MERS-CoV, and SARS-CoV-2 have so far been recognized as Human Coronaviruses (HCoVs). Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is currently the greatest concern for humanity. Despite the overflow of research on SARS-CoV-2 and other HCoVs published every week, existing knowledge in this area is insufficient for the complete understanding of the viruses and the diseases caused by them. This review is based on the analysis of 210 published works, and it attempts to cover the basic biology of coronaviruses, including the genetic characteristics, life cycle, and host-pathogen interaction, pathogenesis, the antiviral drugs, and vaccines against HCoVs, especially focusing on SARS-CoV-2. Furthermore, we will briefly discuss the potential link between extracellular vesicles (EVs) and SARS-CoV-2/COVID-19 pathophysiology.
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Affiliation(s)
- Homa Nath Sharma
- Microbiology Program, Department of Biological Sciences, Alabama State University, Montgomery, AL 36104, USA;
| | | | - Qiana L. Matthews
- Microbiology Program, Department of Biological Sciences, Alabama State University, Montgomery, AL 36104, USA;
- Department of Biological Sciences, Alabama State University, Montgomery, AL 36104, USA;
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Oh EJ, Yoon JH, Park KH, Bae HJ, Yun SJ, Min GJ, Park SS, Park S, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Kim HJ, Min CK, Cho SG, Han K, Lee JW. Natural-killer cell cytotoxicity as a diagnostic and prognostic marker for adult patients with secondary hemophagocytic lymphohistiocytosis: a prospective phase II observational study. Ther Adv Hematol 2021; 12:20406207211020544. [PMID: 34104375 PMCID: PMC8172956 DOI: 10.1177/20406207211020544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) can be life-threatening if not detected and treated appropriately. The diagnosis of HLH can be confusing due to other similar febrile diseases that present with cytopenia. Natural-killer cell (NK)-cytotoxicity is an important diagnostic parameter for primary HLH; however, its role in secondary HLH in adults has not been well-elucidated. METHODS We prospectively enrolled 123 adult patients with febrile conditions accompanied by cytopenia or marrow hemophagocytosis. A diagnosis of HLH was based on HLH-2004 criteria and treated based on HLH-94 protocol. NK-cytotoxicity was calculated at the time of diagnosis by K562-cell direct lysis using flow-cytometry. RESULTS HLH (n = 60) was determined to be caused by Epstein-Barr virus (EBV) (n = 11), infection other than EBV (n = 16), malignancies (n = 19), and unknown (n = 14). Febrile diseases other than HLH (n = 63) were diagnosed as autoimmune disease (n = 22), malignancies (n = 21), infection (n = 12), non-malignant hematological diseases (n = 6), and unknown (n = 2). A lower NK-cytotoxicity level was observed at diagnosis in patients with HLH, compared with other causes of febrile disease (12.1% versus 26.2%, p < 0.001). However, NK-cytotoxicity had a borderline effect on diagnosis of HLH, with an area under receiver operation characteristic curve of 0.689. It also showed no significant role for the prediction of survival outcome. Multivariate analysis revealed that malignant disease and high ferritin level were related with poor survival outcome. In non-malignant disease subgroups, old age, EBV-association, and low NK-cytotoxicity were related with poor survival. CONCLUSIONS Febrile disease with cytopenia was associated with decreased NK-cytotoxicity, especially in adults with HLH; however, its diagnostic role for adult HLH is still arguable. The diagnostic criteria for adult HLH should be further discussed. TRIAL REGISTRATION Clinical Research Information Service [Internet]; Osong (Chungcheongbuk-do), Korea, Centers for Disease Control and Prevention, Ministry of Health and Welfare (Republic of Korea); https://cris.nih.go.kr/cris/index.jsp; Feb, 16th 2016; KCT0001886 (KC15TISE0936).
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Affiliation(s)
- Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Ki Hyun Park
- Department of Biomedical Science, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Joo Bae
- Department of Biomedical Science, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - So Jeong Yun
- Department of Biomedical Science, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Soo Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Silvia Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyungja Han
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Macrophage activation syndrome (MAS) is a severe, potentially life-threatening complication of systemic juvenile idiopathic arthritis (s-JIA). An immunological feature is the excessive activation and proliferation of T lymphocytes and macrophages. Massive hypercytokinemia is strongly associated with its pathogenesis, particularly the overproduction of interleukin (IL)-1, IL-6 and IL-18; interferon (IFN)-γ; and tumor necrosis factor (TNF)-α. Furthermore, heterozygous mutations in causative genes for primary hemophagocytic lymphohistiocytosis and in vivo exposure to highly elevated levels of IL-6 and IL-18 might induce natural killer cell dysfunction and decrease their numbers, respectively. A proper diagnosis is important to begin appropriate therapeutic interventions and change an unfavorable prognosis. The 2016 ACR/EULAR classification criteria for MAS have a high diagnostic performance; however, the diagnostic sensitivity for onset is relatively low. Therefore, careful monitoring of laboratory values during the course of MAS is necessary to diagnose it early in s-JIA. Further studies on the diagnosis and monitoring of disease activity using serum cytokine profile and a targeted cytokine strategy are required.
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Affiliation(s)
- Masaki Shimizu
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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35
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Salvati L, Di Renzo A, Moscardelli S, Natali L, Claudio F, Viscido A. Secondary hemophagocytic lymphohistiocytosis: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021060. [PMID: 33944851 PMCID: PMC8142758 DOI: 10.23750/abm.v92is1.8836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/03/2019] [Indexed: 11/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hematologic syndrome presenting either as an inherited life-threatening inflammatory disorder in children or as a secondary disease in adults. Inherited HLH involves inborn defects in lymphocytes and includes autosomal recessive and X-linked disorders characterized by uncontrolled activation of T cells and macrophages and overproduction of inflammatory cytokines. Secondary or acquired HLH occurs in the settings of infections, systemic connective tissue disease and lymphoid malignancies, possibly due to underlying genetic predisposition to develop HLH. The mechanisms leading to secondary HLH have yet to be fully determined and the disease remains frequently undiagnosed and thereby untreated. Herewith we report the case of an 83-year old Caucasian male who referred to our Division of Internal Medicine and Nephrology due to marked asthenia associated with fever, mental confusion, drowsiness and hyporexia, who was ultimately diagnosed with HLH secondary to anaplastic B cell lymphoma. This case report illustrates the difficulties in the diagnostic workup of HLH, mainly related to early identification of the underlying disease and rapid instauration of appropriate therapy.
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36
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Morgan JM, Bachim A, Cruz AT, Donaruma-Kwoh M. Screening for hemophagocytic lymphohistiocytosis in child abuse evaluations: Twelve years of data. CHILD ABUSE & NEGLECT 2021; 113:104944. [PMID: 33486258 DOI: 10.1016/j.chiabu.2021.104944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Laboratory evaluation is commonly integrated into evaluation of children with suspected physical abuse to identify occult injury and potential mimics of abuse, including hemophagocytic lymphohistiocytosis (HLH). We evaluated the utility of ferritin in laboratory screening panels for physical abuse. OBJECTIVE(S) To determine if hyperferritinemia is a useful screening marker of HLH in physical abuse diagnostic evaluations. PARTICIPANTS AND SETTING Children being evaluated for physical abuse at a quaternary pediatric referral and level one trauma center in Houston, Texas. METHODS We conducted a 12-year (2003 - 2015) retrospective descriptive analysis of all ferritin values obtained as part of routine screening panels for physical child abuse. Medical records were abstracted for patients with ferritin > 500 ng/mL. RESULTS 2954 ferritin levels were obtained in 3091 encounters for suspected physical abuse (median age 6.5 months, interquartile range 2.3-23.5 months). Elevated ferritin was found in 82/2954 (2.8 %); no child evaluated for physical abuse was found to have HLH (95 % CI: 0-4.5%). The child abuse team was consulted in 48/82 (58.5 %) of cases, with the final impression being physical abuse in 33/48 (68.8 %). CONCLUSIONS We found no instances where HLH was identified by institutional screening panels. The inclusion of ferritin in the screening panel was not beneficial. The presence of hyperferritinemia should not cast medical or legal doubt on physical abuse diagnoses when there is a high index of clinical suspicion. Novel hypotheses from case reports and case series should be studied more rigorously before affecting system change.
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Affiliation(s)
- Joy M Morgan
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA.
| | - Angela Bachim
- Department of Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Andrea T Cruz
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Marcella Donaruma-Kwoh
- Department of Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA
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37
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Meenakshi‐Sundaram S, Sankaranarayanan M, Jeyaraman M, Ayyappan C, Karthik SN, Pandi S. Super refractory status in a case of Febrile Infection-Related Epilepsy Syndrome due to hemophagocytic lymphocytic histiocytosis. Epilepsia Open 2021; 6:22-27. [PMID: 33681644 PMCID: PMC7918320 DOI: 10.1002/epi4.12454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/16/2020] [Accepted: 11/18/2020] [Indexed: 11/06/2022] Open
Abstract
A 14-year-old boy presented with a prodromal respiratory infection followed by super refractory status epilepticus. A diagnosis of Febrile Infection-Related Epilepsy Syndrome (FIRES) was made. Initial MRI study and CSF analysis were normal. He required multiple anticonvulsants owing to the refractory nature of the seizures. The course of the illness was rather stormy, laced with various medical problems viz. hepatic dysfunction, sepsis, hemodynamic, and hematological abnormalities which posed several challenges in the management. Hemophagocytic lymphocytic histiocytosis (HLH) was identified as the etiology of the illness and was treated but without success. The case report highlights the several immunomodulatory strategies that were employed to treat the disease, despite which the outcome was unfavorable.
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Affiliation(s)
| | | | | | - Chitra Ayyappan
- Department of PediatricsApollo Speciality HospitalsMaduraiIndia
| | | | - Suresh Pandi
- Department of NeurosciencesApollo Speciality HospitalsMaduraiIndia
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38
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Auerbach A, Schmieg JJ, Aguilera NS. Pediatric Lymphoid and Histiocytic Lesions in the Head and Neck. Head Neck Pathol 2021; 15:41-58. [PMID: 33723759 PMCID: PMC7959275 DOI: 10.1007/s12105-020-01257-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/19/2020] [Indexed: 12/31/2022]
Abstract
Lymphoid and histiocytic lesions of the head and neck in pediatric patients is a fascinating topic as most of these lesions are benign, but that the neoplastic cases are essential to diagnose accurately for appropriate treatment. It is thought that 90% of children will have palpable lymph nodes between the ages of 4 to 8; most, but not all, are non-malignant and some resolve spontaneously without treatment. This paper will look at many of the benign and malignant lesions of both lymphocytic and histiocytic origin that present in the head and neck of children focusing on their diagnostic criteria. There is a very pertinent discussion of nonmalignant lymphoid proliferations, as infections and other reactive conditions dominate the pathology of pediatric lymphohistiocytic head and neck lesions. Discussion of those lymphomas which arise more frequently in the head and neck focuses on those seen in children and young adults such as classic Hodgkin lymphoma and Burkitt lymphoma, as well as new more controversial entities such as pediatric-type follicular lymphoma. Histiocytic lesions, both benign and malignant, are described and may be challenging to diagnose.
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Affiliation(s)
- A Auerbach
- The Joint Pathology Center, Silver Spring, MD, USA.
| | - J J Schmieg
- The Joint Pathology Center, Silver Spring, MD, USA
| | - N S Aguilera
- University of Virginia Health System, Charlottesville, VA, USA
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39
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Guo HY, Sun J, Su Y, Zhang Q, Hua R, Xia X, Fang D. Thrombotic microangiopathy led to acute kidney injury in an infant with hemophagocytic lymphohistiocytosis: A case report. Exp Ther Med 2021; 21:396. [PMID: 33680118 PMCID: PMC7918195 DOI: 10.3892/etm.2021.9827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/18/2020] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but fatal clinical syndrome frequently complicated by acute kidney injury (AKI) and acute tubular necrosis. Renal thrombotic microangiopathy (TMA) is a specific pathological feature of childhood HLH and few cases have been reported among infants. The present study presents a rare case of HLH with TMA in an infant. A 15-month-old infant with a week-long history of fever was admitted to hospital. The infant presented with AKI and subsequently a reduction in platelet and hemoglobin levels. TMA was diagnosed by kidney biopsy and the clinical, laboratory and bone marrow biopsy findings met the criteria of HLH. Due to a progressive increase in serum creatinine levels, hemodialysis was initiated on the second day following admission. Dexamethasone was administered to treat both the fever and HLH. The patient's body temperature returned to a normal range and platelet and hemoglobin levels were stable after 14 days of admission. Renal function stabilized on day 21. The results of genetic testing did not identify any disease-related variations. Childhood HLH is a severe condition and mortality can be reduced by early diagnosis and correct treatment. For patients with HLH and AKI, the possible role of TMA should be considered. Renal biopsy can help to identify the cause of AKI and can be performed when the patient's condition is stable.
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Affiliation(s)
- Hai-Yan Guo
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Jingmin Sun
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Yue Su
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast BT12 6BA, Northern Ireland, UK
| | - Qin Zhang
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Ran Hua
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Xun Xia
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Deng Fang
- Department of Nephrology, Anhui Provincial Children's Hospital, Hefei, Anhui 230022, P.R. China
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40
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Yokota S, Miyamae T, Kuroiwa Y, Nishioka K. Novel Coronavirus Disease 2019 (COVID-19) and Cytokine Storms for More Effective Treatments from an Inflammatory Pathophysiology. J Clin Med 2021; 10:jcm10040801. [PMID: 33671159 PMCID: PMC7922214 DOI: 10.3390/jcm10040801] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 12/15/2022] Open
Abstract
The Novel Coronavirus Disease 2019 (COVID-19) has swept the world and caused a global pandemic. SARS-CoV-2 seems to have originated from bats as their reservoir hosts over time. Similar to SARS-CoV, this new virus also exerts its action on the human angiotensin-converting enzyme 2. This action causes infections in cells and establishes an infectious disease, COVID-19. Against this viral invasion, the human body starts to activate the innate immune system in producing and releasing proinflammatory cytokines such as IL-6, IL-1β, IL-8, TNF-α, and other chemokines, such as G-CSF, IP10 and MCPl, which all develop and increase the inflammatory response. In cases of COVID-19, excessive inflammatory responses occur, and exaggerated proinflammatory cytokines and chemokines are detected in the serum, resulting in cytokine release syndrome or cytokine storm. This causes coagulation abnormalities, excessive oxidation developments, mitochondrial permeability transition, vital organ damage, immune system failure and eventually progresses to disseminated intravascular coagulation and multiple organ failure. Additionally, the excessive inflammatory responses also cause mitochondrial dysfunction due to progressive and persistent stress. This damages cells and mitochondria, leaving products containing mitochondrial DNA and cell debris involved in the excessive chronic inflammation as damage-associated molecular patterns. Thus, the respiratory infection progressively leads to disseminated intravascular coagulation from acute respiratory distress syndrome, including vascular endothelial cell damage and coagulation-fibrinolysis system disorders. This condition causes central nervous system disorders, renal failure, liver failure and, finally, multiple organ failure. Regarding treatment for COVID-19, the following are progressive and multiple steps for mitigating the excessive inflammatory response and subsequent cytokine storm in patients. First, administering of favipiravir to suppress SARS-CoV-2 and nafamostat to inhibit ACE2 function should be considered. Second, anti-rheumatic drugs (monoclonal antibodies), which act on the leading cytokines (IL-1β, IL-6) and/or cytokine receptors such as tocilizumab, should be administered as well. Finally, melatonin may also have supportive effects for cytokine release syndrome, resulting in mitochondrial function improvement. This paper will further explore these subjects with reports mostly from China and Europe.
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Affiliation(s)
- Shumpei Yokota
- Department of Pediatrics, Yokohama City University, Yokohama 236-0004, Japan;
- Fuji-Toranomon Children’s Center, Gotemba 412-0045, Japan
- Japan Medical Research Foundation (JMRF), Tokyo 135-0063, Japan;
- Japan College of Fibromyalgia Investigation (JCFI), Tokyo 160-0022, Japan
- Correspondence:
| | - Takako Miyamae
- Pediatric Rheumatology, Institute of Rheumatology, Tokyo Women’s Medical University, Tokyo 162-0054, Japan;
| | - Yoshiyuki Kuroiwa
- Department of Pediatrics, Yokohama City University, Yokohama 236-0004, Japan;
- Chairman of Stroke Center, Teikyo University School of Medicine Mizonokuchi Hospital, Kawasaki 192-0395, Japan
- Japan Society of Neurovegetative Research (JSNR), Tokyo 170-0002, Japan
| | - Kusuki Nishioka
- Japan Medical Research Foundation (JMRF), Tokyo 135-0063, Japan;
- Global Health Innovation Policy Program (GHIPP), National Graduate Institute for Policy Studies (GRIPS), Tokyo 106-0032, Japan
- American College of Rheumatology (ACR), Atlanta, GA 30319, USA
- St. Marianna University, Kawasaki 216-8511, Japan
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41
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Keenan C, Nichols KE, Albeituni S. Use of the JAK Inhibitor Ruxolitinib in the Treatment of Hemophagocytic Lymphohistiocytosis. Front Immunol 2021; 12:614704. [PMID: 33664745 PMCID: PMC7923355 DOI: 10.3389/fimmu.2021.614704] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome driven by overactive T cells and macrophages that abundantly secrete numerous pro-inflammatory cytokines, including interferon (IFN)-gamma, interleukin (IL)-1-beta, IL-2, IL-6, IL-10, IL-18, and tumor necrosis factor (TNF). The release of these and other cytokines underlies many of the clinical and pathologic manifestations of HLH, which if left untreated, can lead to multi-organ failure and death. The advent of etoposide-based regimens, such as the Histiocyte Society HLH-94 and HLH-2004 protocols, has substantially decreased the mortality associated with HLH. Nevertheless, the 5-year survival remains low at ~60%. To improve upon these results, studies have focused on the use of novel cytokine-directed therapies to dampen inflammation in HLH. Among the agents being tested is ruxolitinib, a potent inhibitor of the Janus Kinase (JAK) and Signal Transducer and Activation of Transcription (STAT) pathway, which functions downstream of many HLH-associated cytokines. Here, we review the basic biology of HLH, including the role of cytokines in disease pathogenesis, and discuss the use of ruxolitinib in the treatment of HLH.
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Affiliation(s)
- Camille Keenan
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sabrin Albeituni
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
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42
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Perico L, Benigni A, Casiraghi F, Ng LFP, Renia L, Remuzzi G. Immunity, endothelial injury and complement-induced coagulopathy in COVID-19. Nat Rev Nephrol 2021; 17:46-64. [PMID: 33077917 PMCID: PMC7570423 DOI: 10.1038/s41581-020-00357-4] [Citation(s) in RCA: 359] [Impact Index Per Article: 119.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 01/08/2023]
Abstract
In December 2019, a novel coronavirus was isolated from the respiratory epithelium of patients with unexplained pneumonia in Wuhan, China. This pathogen, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes a pathogenic condition that has been termed coronavirus disease 2019 (COVID-19) and has reached pandemic proportions. As of 17 September 2020, more than 30 million confirmed SARS-CoV-2 infections have been reported in 204 different countries, claiming more than 1 million lives worldwide. Accumulating evidence suggests that SARS-CoV-2 infection can lead to a variety of clinical conditions, ranging from asymptomatic to life-threatening cases. In the early stages of the disease, most patients experience mild clinical symptoms, including a high fever and dry cough. However, 20% of patients rapidly progress to severe illness characterized by atypical interstitial bilateral pneumonia, acute respiratory distress syndrome and multiorgan dysfunction. Almost 10% of these critically ill patients subsequently die. Insights into the pathogenic mechanisms underlying SARS-CoV-2 infection and COVID-19 progression are emerging and highlight the critical role of the immunological hyper-response - characterized by widespread endothelial damage, complement-induced blood clotting and systemic microangiopathy - in disease exacerbation. These insights may aid the identification of new or existing therapeutic interventions to limit the progression of early disease and treat severe cases.
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Affiliation(s)
- Luca Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Lisa F P Ng
- Infectious Diseases Horizontal Technology Centre (ID HTC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Laurent Renia
- Infectious Diseases Horizontal Technology Centre (ID HTC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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43
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Mudde ACA, Booth C, Marsh RA. Evolution of Our Understanding of XIAP Deficiency. Front Pediatr 2021; 9:660520. [PMID: 34222142 PMCID: PMC8247594 DOI: 10.3389/fped.2021.660520] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 12/17/2022] Open
Abstract
X-linked inhibitor of apoptosis (XIAP) deficiency is a rare inborn error of immunity first described in 2006. XIAP deficiency is characterised by immune dysregulation and a broad spectrum of clinical manifestations, including haemophagocytic lymphohistiocytosis (HLH), inflammatory bowel disease (IBD), hypogammaglobulinemia, susceptibility to infections, splenomegaly, cytopaenias, and other less common autoinflammatory phenomena. Since the first description of the disease, many XIAP deficient patients have been identified and our understanding of the disease has grown. Over 90 disease causing mutations have been described and more inflammatory disease manifestations, such as hepatitis, arthritis, and uveitis, are now well-recognised. Recently, following the introduction of reduced intensity conditioning (RIC), outcomes of allogeneic haematopoietic stem cell transplantation (HSCT), the only curative treatment option for XIAP deficiency, have improved. The pathophysiology of XIAP deficiency is not fully understood, however it is known that XIAP plays a role in both the innate and adaptive immune response and in immune regulation, most notably through modulation of tumour necrosis factor (TNF)-receptor signalling and regulation of NLRP3 inflammasome activity. In this review we will provide an up to date overview of both the clinical aspects and pathophysiology of XIAP deficiency.
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Affiliation(s)
- Anne C A Mudde
- Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Claire Booth
- Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Immunology and Gene Therapy, Great Ormond Street Hospital, London, United Kingdom
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
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44
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Al Nasrallah N, Al-Hader A, Samala N, Sears CR. Hemophagocytic Lymphohistiocytosis in the Medical ICU: A Single-Institution Cohort Study on Acute Liver Failure and Mortality. Crit Care Explor 2021; 3:e0318. [PMID: 33458685 PMCID: PMC7803668 DOI: 10.1097/cce.0000000000000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory disorder that is associated with high morbidity and mortality in the ICU. It has also been associated with acute liver failure. DESIGN Retrospective observational study. SETTING Tertiary-care medical ICU. PATIENTS Thirty-one patients critically ill with hemophagocytic lymphohistiocytosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed a comprehensive review of critically ill hemophagocytic lymphohistiocytosis patients admitted to a tertiary-care medical ICU from January 2012 to December 2018. Most patients presented with constitutional symptoms and elevated liver enzymes and thrombocytopenia were common upon hospital admission. ICU admission laboratory and clinical variables were used to calculate Acute Physiology and Chronic Health Evaluation II, hemophagocytic syndrome diagnostic score, and model for end-stage liver disease. Mean age of the cohort was 48.1 years, and 45% were male. The mortality rate was 65% at 28 days and 77% at 1 year. About 28-day survivors were younger, had lower mean Acute Physiology and Chronic Health Evaluation II score (16.5 vs 23.0; p = 0.004), and higher mean hemophagocytic syndrome diagnostic score (249.1 vs 226.0; p = 0.032) compared with nonsurvivors. Survivors were less likely to receive mechanical ventilation, renal replacement therapy, or vasopressor support and were more likely to receive chemotherapy for hemophagocytic lymphohistiocytosis. In this ICU cohort, 29% were diagnosed with acute liver failure, of whom only 22% developed acute liver failure early during their hospital stay. Acute liver failure was associated with a higher model for end-stage liver disease score upon hospital admission. Available histology in those that developed acute liver failure showed massive hepatic necrosis, or histiocytic or lymphocytic infiltrates. CONCLUSIONS Patients admitted to the ICU with hemophagocytic lymphohistiocytosis have a high mortality. Those who survived had lower Acute Physiology and Chronic Health Evaluation scores, had higher hemophagocytic syndrome diagnostic scores, are more likely to receive hemophagocytic lymphohistiocytosis specific chemotherapy, and are less likely to have organ failure. Hemophagocytic lymphohistiocytosis can be associated with acute liver failure especially when model for end-stage liver disease score is elevated upon admission.
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Affiliation(s)
- Nawar Al Nasrallah
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Ahmad Al-Hader
- Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Niharika Samala
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN
| | - Catherine R Sears
- Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
- Division of Pulmonary Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Yu TY, Lu MY, Lin KH, Chang HH, Chou SW, Lin DT, Jou ST, Yang YL. Outcomes and prognostic factors associated with 180-day mortality in Taiwanese pediatric patients with Hemophagocytic Lymphohistiocytosis. J Formos Med Assoc 2020; 120:1061-1068. [PMID: 33218852 DOI: 10.1016/j.jfma.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/21/2020] [Accepted: 10/26/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND/PURPOSE Hemophagocytic lymphohistiocytosis (HLH), a rarely occurring syndrome with various triggers, is associated with early mortality. Owing to a lack of sufficient corresponding data in Taiwan, this study aimed to identify the outcome and potential factors associated with 180-day mortality in pediatric HLH. METHODS This retrospective study analyzed clinical and laboratory data on pediatric patients diagnosed with HLH at our institute (1995-2019). Logistic regression analysis was conducted to determine the associations between various factors and 180-day mortality. RESULTS Overall, 48 patients had HLH; their median age at diagnosis was 5 years (interquartile range: 2-11 years). Clinical presentations and laboratory parameters required for diagnosis included fever (98%), splenomegaly (79%), hyperferritinemia (98%), hemophagocytosis (94%), thrombocytopenia (90%), anemia (63%), hypertriglyceridemia (68%), and neutropenia (57%). The 5-year overall survival (OS) rate was 49%. Of 22 patients who had died at the last follow-up, 15 (68%) died within 180 days after diagnosis. In the multivariate analysis, hemoglobin (odds ratio [OR]: 0.564, p = 0.024) and triglyceride (OR: 1.004, p = 0.049) were significantly associated with 180-day mortality. Higher triglyceride levels at diagnosis were related to significantly lower 180-day OS rates (52.9% vs. 86.1%, p = 0.018). CONCLUSION The overall outcome in our cohort was similar to that reported in some of the largest international cohorts. Hypertriglyceridemia and anemia may be indicative of poor prognoses in pediatric HLH patients independently and may be used to guide treatment strategy formulations for better outcomes.
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Affiliation(s)
- Teng-Yang Yu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Wei Chou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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46
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Singh A, Chauhan A, Padole V, Chhabra D, Upneja R. The great masquerader: Hemophagocytic lymphohistiocytosis secondary to cytomegalovirus infection in an immunocompetent young man. J Family Med Prim Care 2020; 9:3762-3765. [PMID: 33102367 PMCID: PMC7567245 DOI: 10.4103/jfmpc.jfmpc_274_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/13/2020] [Accepted: 04/03/2020] [Indexed: 11/15/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, poorly recognized and underdiagnosed syndrome of excessive immune activation, which is rapidly fatal. HLH can occur as a familial or secondary disorder. Secondary HLH is most commonly associated with infections, malignancies, or autoimmune diseases. It primarily affects patients with a compromised immune system and rarely presents in immunocompetent individuals. Acute cytomegalovirus (CMV) associated HLH in the immunocompetent individual is extremely rare and only documented in five case reports till date. We, hereby, report a case of 18 years old young immunocompetent man who was diagnosed to have HLH secondary to CMV infection.
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Affiliation(s)
- Akanksha Singh
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Ajay Chauhan
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vaibhav Padole
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Devyani Chhabra
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Raghav Upneja
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
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Hiser W, Landgarten M, Zhou XJ. Hemophagocytic syndrome with histiocytic glomerulopathy associated with ovarian serous carcinoma. Proc (Bayl Univ Med Cent) 2020; 34:153-155. [PMID: 33456183 DOI: 10.1080/08998280.2020.1805715] [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: 10/23/2022] Open
Abstract
Histiocytic glomerulopathy, an entity characterized by glomerular infiltration by foamy histiocytes with endothelial injury, has recently been reported as a manifestation of hemophagocytic syndrome. We report a case of histiocytic glomerulopathy in a woman receiving chemotherapy for ovarian serous carcinoma with proteinuria in whom hemophagocytic syndrome was not clinically suspected.
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Affiliation(s)
- Wesley Hiser
- Department of Pathology, Baylor University Medical Center, Dallas, Texas.,Renal Path Diagnostics, Pathologists BioMedical Laboratories/PathGroup, Lewisville, Texas
| | | | - Xin Jin Zhou
- Department of Pathology, Baylor University Medical Center, Dallas, Texas.,Renal Path Diagnostics, Pathologists BioMedical Laboratories/PathGroup, Lewisville, Texas
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48
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Opoka-Winiarska V, Grywalska E, Roliński J. Could hemophagocytic lymphohistiocytosis be the core issue of severe COVID-19 cases? BMC Med 2020; 18:214. [PMID: 32664932 PMCID: PMC7360379 DOI: 10.1186/s12916-020-01682-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19, a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), commonly presents as fever, cough, dyspnea, and myalgia or fatigue. Although the majority of patients with COVID-19 have mild symptoms, some are more prone to serious outcomes, including pneumonia, acute respiratory distress syndrome (ARDS), and even death. Hemophagocytic lymphohistiocytosis (HLH) is a severe, life-threatening inflammatory syndrome associated with intense cytokine release (also known as a "cytokine storm"). Similar to COVID-19, HLH is characterized by aggressive course leading to multi-organ failure. MAIN TEXT The purpose of this review article is to draw attention to the possibility of the complication of HLH in patients with the severe course of COVID-19. Indeed, some of the clinical characteristics observed in the more severe cases of COVID-19 are reminiscent of secondary HLH (which can be triggered by infections, malignancies, rheumatological diseases, or autoimmune/immunodeficiency conditions). The pathogenesis of SARS-CoV-2 infection also suggests that HLH or a similar hyperinflammatory syndrome is the cause of the severe course of the infection. CONCLUSION The pathogenesis and clinical symptoms of severe COVID-19 indicate that an increased inflammatory response corresponding to HLH is occurring. Therefore, patients with severe COVID-19 should be screened for hyperinflammation using standard laboratory tests to identify those for whom immunosuppressive therapy may improve outcomes.
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Affiliation(s)
- Violetta Opoka-Winiarska
- Department of Paediatric Pulmonology and Rheumatology, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland
| | - Ewelina Grywalska
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Chodzki 4a Street, 20-093 Lublin, Poland
- Department of Clinical Immunology, St. John’s Cancer Hospital, K. Jaczewskiego 7 St, 20–090 Lublin, Poland
| | - Jacek Roliński
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Chodzki 4a Street, 20-093 Lublin, Poland
- Department of Clinical Immunology, St. John’s Cancer Hospital, K. Jaczewskiego 7 St, 20–090 Lublin, Poland
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Debliquis A, Harzallah I, Mootien JY, Poidevin A, Labro G, Mejri A, Lamarque M, Kuteifan K, Drénou B. Haemophagocytosis in bone marrow aspirates in patients with COVID-19. Br J Haematol 2020; 190:e70-e73. [PMID: 32529634 PMCID: PMC7307071 DOI: 10.1111/bjh.16860] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Agathe Debliquis
- Département d'Hématologie, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Inès Harzallah
- Département d'Hématologie, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Joy Y Mootien
- Service de Réanimation médicale, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Antoine Poidevin
- Service de Réanimation médicale, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Guylaine Labro
- Service de Réanimation médicale, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Amira Mejri
- Département d'Hématologie, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Mathilde Lamarque
- Département d'Hématologie, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Khaldoun Kuteifan
- Service de Réanimation médicale, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
| | - Bernard Drénou
- Département d'Hématologie, Groupe Hospitalier de la région Mulhouse Sud Alsace, Mulhouse, France
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50
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Parackova Z, Milota T, Vrabcova P, Smetanova J, Svaton M, Freiberger T, Kanderova V, Sediva A. Novel XIAP mutation causing enhanced spontaneous apoptosis and disturbed NOD2 signalling in a patient with atypical adult-onset Crohn's disease. Cell Death Dis 2020; 11:430. [PMID: 32514016 PMCID: PMC7280281 DOI: 10.1038/s41419-020-2652-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022]
Abstract
X-linked inhibitor of apoptosis (XIAP) is the most potent human inhibitor of apoptosis, and is also involved in NOD2-dependent NFκB and MAPK signalling cascade activation. The absence or defective function of XIAP leads to the development of a rare and severe primary immunodeficiency known as X-linked lymphoproliferative syndrome type 2 (XLP-2), which is characterized by a triad of clinical manifestations, including a high incidence of haemophagocytic lymphohistiocytosis (HLH), lymphoproliferation and inflammatory bowel disease (IBD), usually with very early onset. Here, we present a novel XIAP mutation identified in a patient with atypical adult-onset IBD complicated by relapsing HLH, splenomegaly and sarcoid-like disease. The c.266delA mutation in the XIAP gene creates a premature stop codon, and causes a severe reduction in XIAP protein expression. The mutation is also associated with impaired spontaneous and staurosporine- and PMA-induced apoptosis accompanied by significantly increased expression of pro-apoptotic genes. We also confirmed the negative impact of this particular XIAP mutation on NOD2-dependent NFκB and MAPK activation, while NOD2-independent activation was found to be unaffected. Moreover, we assume that the mutation has an impact on the overproduction of IL-12 and IFNγ, the shift towards the Th1 immune response and increased numbers of central memory and effector memory CD4+ and CD8+ T cells. All these changes contribute to immune dysregulation and the clinical manifestation of XLP-2.
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Affiliation(s)
- Zuzana Parackova
- Department of Immunology, 2nd Faculty of Medicine Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic.
| | - Tomas Milota
- Department of Immunology, 2nd Faculty of Medicine Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Petra Vrabcova
- Department of Immunology, 2nd Faculty of Medicine Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Jitka Smetanova
- Department of Immunology, 2nd Faculty of Medicine Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Michael Svaton
- CLIP-Childhood Leukaemia Investigation Prague, Department of Paediatric Haematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Tomas Freiberger
- Molecular Genetics Laboratory, Center of Cardiovascular Surgery and Transplantation, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Veronika Kanderova
- CLIP-Childhood Leukaemia Investigation Prague, Department of Paediatric Haematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
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