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AlJabban A, Evans MG, Fell GG, Guccione JP, Edwards RA, Pinkus GS, Padera RF, Pozdnyakova O, Kim AS. Autopsy findings from patients diagnosed with COVID-19 demonstrate unique morphological patterns in bone marrow and lymph node. J Clin Pathol 2024; 77:622-627. [PMID: 37290912 DOI: 10.1136/jcp-2023-208875] [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: 03/07/2023] [Accepted: 04/30/2023] [Indexed: 06/10/2023]
Abstract
AIMS The identification of haemophagocytosis in bone marrow (BM) is recurrently identified in patients with severe COVID-19. These initial COVID-19 autopsy studies have afforded valuable insight into the pathophysiology of this disease; however, only a limited number of case series have focused on lymphoid or haematopoietic tissues. METHODS BM and lymph node (LN) specimens were obtained from adult autopsies performed between 1 April 2020 and 1 June 2020, for which the decedent had tested positive for SARS-CoV-2. Tissue sections (H&E, CD3, CD20, CD21, CD138, CD163, MUM1, kappa/lambda light chains in situ hybridisation) were examined by two haematopathologists, who recorded morphological features in a blinded fashion. Haemophagocytic lymphohistiocytosis (HLH) was assessed based on HLH 2004 criteria. RESULTS The BM demonstrated a haemophagocytic pattern in 9 out of 25 patients (36%). The HLH pattern was associated with longer hospitalisation, BM plasmacytosis, LN follicular hyperplasia and lower aspartate aminotransferase (AST), as well as ferritin at demise. LN examination showed increased plasmacytoid cells in 20 of 25 patients (80%). This pattern was associated with a low absolute monocyte count at diagnosis, lower white cell count and lower absolute neutrophil count at demise, and lower ferritin and AST at demise. CONCLUSIONS Autopsy results demonstrate distinct morphological patterns in BM, with or without haemophagocytic macrophages, and in LN, with or without increased plasmacytoid cells. Since only a minority of patients met diagnostic criteria for HLH, the observed BM haemophagocytic macrophages may be more indicative of an overall inflammatory state.
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Affiliation(s)
- Ali AlJabban
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Clinical Investigation, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark G Evans
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Geoffrey G Fell
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jack P Guccione
- Los Angeles County Department of Medical Examiner-Coroner, Los Angeles, California, USA
| | - Robert A Edwards
- Department of Pathology and Laboratory Medicine, University of California Irvine, Irvine, California, USA
| | - Geraldine S Pinkus
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert F Padera
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Annette S Kim
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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2
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Papageorgiou D, Gogos C, Akinosoglou K. Macrophage Activation Syndrome in Viral Sepsis. Viruses 2024; 16:1004. [PMID: 39066167 PMCID: PMC11281345 DOI: 10.3390/v16071004] [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: 05/25/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a life-threatening systemic hyperinflammatory syndrome triggered by various infections, particularly viral infections, autoimmune disorders, and malignancy. The condition is characterized by an increased production of proinflammatory cytokines resulting in a cytokine storm and has been associated with poor clinical outcomes. During the COVID-19 pandemic, patients with severe manifestations developed features similar to those of MAS, although these characteristics remained well defined within the lung. Additionally, other viral infections including EBV, the herpes family of viruses, hepatitis viruses, influenza, HIV, and hemorrhagic fevers can be complicated by MAS. The diagnosis and management of the condition remain challenging due to the lack of consensus on specific guidelines, especially among the adult population. Currently, therapeutic options primarily rely on medications that are typically used to treat primary hemophagocytic lymphohistiocytosis, such as corticosteroids and etoposide. In addition, cytokine-targeted therapies present promising treatment options. The objective of this review is to discuss the emergence of MAS in the context of viral infections including, but not limited to, its occurrence in COVID-19.
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Affiliation(s)
- Despoina Papageorgiou
- Department of Medicine, University of Patras, Rio, 26504 Patras, Greece; (C.G.); (K.A.)
| | - Charalambos Gogos
- Department of Medicine, University of Patras, Rio, 26504 Patras, Greece; (C.G.); (K.A.)
- Metropolitan General Hospital, 15562 Athens, Greece
| | - Karolina Akinosoglou
- Department of Medicine, University of Patras, Rio, 26504 Patras, Greece; (C.G.); (K.A.)
- Department of Internal Medicine and Infectious Diseases, University of Patras, Rio, 26504 Patras, Greece
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3
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Ruffer N, Kosch R, Weisel K, Kötter I, Krusche M. [Hemophagocytic lymphohistiocytosis and macrophage activation syndrome : A multidisciplinary challenge]. Z Rheumatol 2024; 83:376-386. [PMID: 38267764 DOI: 10.1007/s00393-023-01472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is characterized by hyperferritinemia, cytopenia, disseminated intravascular coagulopathy and functional disorders of the liver and the central nervous system. The term macrophage activation syndrome is predominantly used for secondary HLH in the context of autoimmune diseases (e.g., systemic juvenile idiopathic arthritis). In addition, malignancies and genetic inborn errors of immunity can predispose to the development of HLH. Infections (e.g., Epstein-Barr virus) in turn represent possible triggers of an acute episode. Due to the unspecific manifestation of the disease, a systematic evaluation of the organ systems is recommended in the clinical and laboratory analytical clarification of hyperinflammatory syndromes. In general, the treatment should be carried out by a multidisciplinary team with expertise in rheumatology, hematological oncology, infectious diseases and intensive care medicine. The primary treatment of HLH usually consists of glucocorticoids and in cases of a rapid deterioration of the condition anakinra (interleukin 1 block) and intravenous immunoglobulins can be employed. Treatment of the underlying disease should be consequently carried out in parallel, together with antimicrobial treatment.
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Affiliation(s)
- Nikolas Ruffer
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Ricardo Kosch
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Katja Weisel
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ina Kötter
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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4
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Kundura L, Cezar R, Ballongue E, André S, Michel M, Mettling C, Lozano C, Vincent T, Muller L, Lefrant JY, Roger C, Claret PG, Duvnjak S, Loubet P, Sotto A, Tran TA, Estaquier J, Corbeau P. Low Percentage of Perforin-Expressing NK Cells during Severe SARS-CoV-2 Infection: Consumption Rather than Primary Deficiency. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:1105-1112. [PMID: 38345346 DOI: 10.4049/jimmunol.2300359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 12/05/2023] [Indexed: 03/20/2024]
Abstract
Genetic defects in the ability to deliver effective perforin have been reported in patients with hemophagocytic lymphohistiocytosis. We tested the hypothesis that a primary perforin deficiency might also be causal in severe SARS-CoV-2 infection. We recruited 54 volunteers confirmed as being SARS-CoV-2-infected by RT-PCR and admitted to intensive care units or non-intensive care units and age- and sex-matched healthy controls. Compared with healthy controls, the percentage of perforin-expressing CD3-CD56+ NK cells quantified by flow cytometry was low in COVID-19 patients (69.9 ± 17.7 versus 78.6 ± 14.6%, p = 0.026). There was no correlation between the proportions of perforin-positive NK cells and T8 lymphocytes. Moreover, the frequency of NK cells producing perforin was neither linked to disease severity nor predictive of death. Although IL-6 is known to downregulate perforin production in NK cells, we did not find any link between perforin expression and IL-6 plasma level. However, we unveiled a negative correlation between the degranulation marker CD107a and perforin expression in NK cells (r = -0.488, p = 10-4). PRF1 gene expression and the frequency of NK cells harboring perforin were normal in patients 1 y after acute SARS-CoV-2 infection. A primary perforin defect does not seem to be a driver of COVID-19 because NK perforin expression is 1) linked neither to T8 perforin expression nor to disease severity, 2) inversely correlated with NK degranulation, and 3) normalized at distance from acute infection. Thus, the cause of low frequency of perforin-positive NK cells appears, rather, to be consumption.
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Affiliation(s)
- Lucy Kundura
- Institute of Human Genetics, UMR9002, CNRS and Montpellier University, Montpellier, France
| | - Renaud Cezar
- Immunology Department, Nîmes University Hospital, Nîmes, France
| | - Emma Ballongue
- Institute of Human Genetics, UMR9002, CNRS and Montpellier University, Montpellier, France
| | - Sonia André
- INSERM U1124, Université de Paris, Paris, France
| | - Moïse Michel
- Immunology Department, Nîmes University Hospital, Nîmes, France
| | - Clément Mettling
- Institute of Human Genetics, UMR9002, CNRS and Montpellier University, Montpellier, France
| | - Claire Lozano
- Immunology Department, Montpellier University Hospital, Montpellier, France
| | - Thierry Vincent
- Immunology Department, Montpellier University Hospital, Montpellier, France
| | - Laurent Muller
- Surgical Intensive Care Department, Nîmes University Hospital, Nîmes, France
| | - Jean-Yves Lefrant
- Surgical Intensive Care Department, Nîmes University Hospital, Nîmes, France
| | - Claire Roger
- Surgical Intensive Care Department, Nîmes University Hospital, Nîmes, France
| | - Pierre-Géraud Claret
- Medical and Surgical Emergency Department, Nîmes University Hospital, Nîmes, France
| | - Sandra Duvnjak
- Gerontology Department, Nîmes University Hospital, Nîmes, France
| | - Paul Loubet
- *Infectious Diseases Department, Nîmes University Hospital, Nîmes, France
| | - Albert Sotto
- *Infectious Diseases Department, Nîmes University Hospital, Nîmes, France
| | - Tu-Anh Tran
- Pediatrics Department, Nîmes University Hospital, Nîmes, France
| | - Jérôme Estaquier
- INSERM U1124, Université de Paris, Paris, France
- Laval University Research Center; Quebec City, Quebec, Canada
| | - Pierre Corbeau
- Institute of Human Genetics, UMR9002, CNRS and Montpellier University, Montpellier, France
- Immunology Department, Nîmes University Hospital, Nîmes, France
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5
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van de Veerdonk FL. COVID-19 Pneumonia and Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:307-319. [PMID: 39117824 DOI: 10.1007/978-3-031-59815-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Virus-associated cytokine storm syndrome (CSS) has been recognized for a long time and the classic viruses associated are the herpes viruses EBV, CMV, and HHV-8 as described in chapters IVa,b. In addition, pandemic viruses such as influenza, SARS, and MERS can result in severe CSS that might ultimately lead to severe acute respiratory distress syndrome (ARDS) and death [1-3]. A new pandemic caused by SARS-CoV-2 that started in 2019 has defined another chapter in the virus-associated CSS. The clinical spectrum of SARS-CoV-2 infection has many faces. In most people, it will be asymptomatic, but it can also result in severe COVID-19 pneumonia, ARDS, and multiorgan failure depending on age, comorbidities, and immune status [4]. In addition, this pandemic has known many different stages and developed in a unique way in the first 2 years. It started in a setting where there was no immunity to the virus and after a year, highly effective vaccines were introduced and herd immunity built up over time. However, vaccine effectiveness was waning over time depending on multiple factors, and novel variant strains of the virus circulated across different areas in the world. Antiviral therapy was developed and introduced, and treatment changed from giving no immunomodulatory treatment, followed by the introduction of corticosteroids [5], and later the addition of more targeted strategies such as JAK inhibitors [6] and blocking IL-6 signaling [7]. Therefore, the scientific literature published on COVID-19 must be seen in the context of a highly dynamic and rapidly changing pandemic, making it difficult to compare results from early studies to more recent reports even within 2 years. Still, a lot has been learned over a very short period. It has become apparent that severe COVID-19 is predominantly a disease of immune dysregulation with components that can be defined as CSS. It has unique features and overlapping characteristics with other CSSs, and immunological treatment addressing the CSS has been extensively explored, which will be described here.
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6
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Kaneko S, Inoue T, Tarumoto N, Haga Y, Yokota K, Yamaguchi H, Okada H. A case of hemophagocytic lymphohistiocytosis in a hemodialysis patient with coronavirus disease 2019. CEN Case Rep 2023; 12:390-396. [PMID: 36864233 PMCID: PMC9982797 DOI: 10.1007/s13730-023-00776-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/06/2023] [Indexed: 03/04/2023] Open
Abstract
During the treatment of a patient on hemodialysis with severe coronavirus disease 2019 (COVID-19), the patient was weaned from extracorporeal membrane oxygenation, which was used to treat severe COVID-19 pneumonia. However, the patient's condition worsened after the peak infection phase of COVID-19 because of acute respiratory distress syndrome with suspected hemophagocytic lymphohistiocytosis (HLH). After a bone marrow biopsy confirmed the diagnosis, methylprednisolone pulse therapy, followed by combination therapy (including oral prednisolone and cyclosporine) was immediately administered, and the patient survived. Because HLH can occur a month or more after the onset of COVID-19, even if the viral load is reduced to the point of being undetectable by reverse transcriptase-polymerase chain reaction, it can be considered to correspond to the "post-acute COVID-19 syndrome," which has recently been proposed. Early intervention is necessary, because HLH can be fatal. Therefore, it is important to know that HLH can occur at any stage of COVID-19 and to pay attention to the patient's progress over time, including checking the HScore.
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Affiliation(s)
- Satoru Kaneko
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0451, Japan
| | - Tsutomu Inoue
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0451, Japan
| | - Norihito Tarumoto
- Department of Infectious Disease and Infection Control, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0451, Japan
| | - Yoshiyuki Haga
- Department of Intensive Care Medicine, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0451, Japan
| | - Kazuhiro Yokota
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0451, Japan
| | - Hiroshi Yamaguchi
- Department of Pathology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-Machi, Iruma-gun, Saitama, 350-0451, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0451, Japan.
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7
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Fadlallah MM, Salman SM, Fadlallah MM, Rahal H. Hemophagocytic Syndrome and COVID-19: A Comprehensive Review. Cureus 2023; 15:e36140. [PMID: 37065291 PMCID: PMC10101193 DOI: 10.7759/cureus.36140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), a hyperinflammatory hyperferritinemic syndrome, is triggered by various etiologies and diseases and can lead to multiorgan dysfunction and death. There are two types of HLH: primary and secondary. Primary HLH (pHLH) is caused by a genetic mutation resulting in dysfunction in cytotoxic T lymphocytes (CTLs), natural killer (NK) cells, hyperactivated immune cells, and hypercytokinemia. In secondary HLH (sHLH), an underlying etiology is the cause of the disease. Infections, malignancy, and autoimmune diseases are well-known triggers for sHLH. Infectious triggers for sHLH are most frequently viruses, where different mechanisms, including dysregulated CTLs and NK cell activity and persistent immune system stimulation, have been reported. Similarly, in severe coronavirus disease 2019 (COVID-19) patients, a hyperinflammatory mechanism leading to hypercytokinemia and hyperferritinemia has been demonstrated. A similar dysfunction in CTLs and NK cells, persistent immune system stimulation with increased cytokines production, and severe end-organ damage have been reported. Therefore, a significant overlap is present between the clinical and laboratory features seen in COVID-19 and sHLH. However, SARS-CoV-2, similar to other viruses, can trigger sHLH. Hence, a diagnostic approach is needed in severe COVID-19 patients presenting with multiorgan failure, in whom sHLH should be considered.
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Yadav G, Malhotra H, Mehta P, Sachu R, Rizvi I, Bharti VR, Kumar M, Kumar N, Ali W, Verma SP, Puri B, Dandu H. Severe COVID-19-associated hyperinflammatory syndrome versus classic hemophagocytic lymphohistiocytosis: similarities, differences, and the way forward. J Investig Med 2023; 71:244-253. [PMID: 36803041 PMCID: PMC9939916 DOI: 10.1177/10815589221140596] [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] [Indexed: 02/20/2023]
Abstract
The hyperinflammatory immune response in severe COVID-19 infection shares features with secondary hemophagocytic lymphohistiocytosis (sHLH) in the form of fever, cytopenia, elevated inflammatory markers, and high mortality. There are contrasting opinions regarding utility of HLH 2004 or HScore in the diagnosis of severe COVID-19-related hyperinflammatory syndrome (COVID-HIS). This was a retrospective study of 47 patients of severe COVID-19 infection, suspected to have COVID-HIS and 22 patients of sHLH to other illnesses, to evaluate the diagnostic utility and limitations of HLH 2004 and/or HScore in context to COVID-HIS and to also evaluate the utility of Temple criteria for predicting severity and outcome in COVID-HIS. Clinical findings, hematological, and biochemical parameters along with the predictor of mortality were compared between two groups. Only 6.4% (3/47) of cases fulfilled ≥5/8 HLH 2004 criteria and only 40.52% (19/47) of patients showed HScore >169 in COVID-HIS group. 65.9% (31/47) satisfied the Temple criteria in COVID-HIS as compared with 40.9% (9/22) in the non-COVID group (p = 0.04). Serum ferritin (p = 0.02), lactate dehydrogenase (p = 0.02), direct bilirubin (p = 0.02), and C-reactive protein (p = 0.03) were associated with mortality in COVID-HIS. Both HScore and HLH-2004 criteria perform poorly for identifying COVID-HIS. Presence of bone marrow hemophagocytosis may help to identify about one-third of COVID-HIS missed by the Temple Criteria.
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Affiliation(s)
- Geeta Yadav
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Hardeep Malhotra
- Department of Neurology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Pankti Mehta
- Department of Rheumatology, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Ruovinuo Sachu
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Imran Rizvi
- Department of Neurology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Vipin Raj Bharti
- Department of Internal Medicine, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Manish Kumar
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Neeraj Kumar
- Department of Neurology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Wahid Ali
- Department of Pathology, King George’s
Medical University, Lucknow, Uttar Pradesh, India
| | - Shailendra Prasad Verma
- Department of Clinical Hematology, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Bipin Puri
- Department of Pediatric Surgery, King
George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Himanshu Dandu
- Department of Internal Medicine, King
George’s Medical University, Lucknow, Uttar Pradesh, India,Himanshu Dandu, Department of Internal
Medicine, King George’s Medical University, Chowk, Lucknow, Uttar Pradesh
226003, India.
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De Ioris MA, Scarselli A, Bracaglia C, Perrotta D, Bernardi S, Santilli V, Ceglie G, Fabozzi F, Agrati C, Prencipe G, Alaggio R, Mastronuzzi A, De Vito R. Common bone marrow signature in COVID-19-associated multisystem inflammatory syndrome in children: A first-wave small case series experience. Pediatr Blood Cancer 2022; 69:e29919. [PMID: 35986692 PMCID: PMC9537984 DOI: 10.1002/pbc.29919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Abstract
The hyper-inflammatory response, also known as multisystem inflammatory syndrome in children (MIS-C), represents a major concern in children with SARS-CoV-2 infection. We report bone marrow features of three patients with MIS-C who were diagnosed during the first wave of the SARS-CoV-2 pandemic. A bone marrow evaluation was performed at onset of the inflammatory condition in order to exclude secondary hemophagocytic lymphohistiocytosis (sHLH). The bone marrows of the patients presented common features: the erythroid and megakaryocytic lineages were prominently affected and hemophagocytosis was moderately increased, differently than observed in sHLH. Megakaryocytopoiesis was increased, representing a peculiar feature of MIS-C differing from sHLH. SARS-CoV-2 RT-PCR and viral panel were studied in bone marrow aspiration samples. MIS-C is a rare complication of SARS-CoV-2 infections in children. An immuno-dysregulation considering both innate and adaptive immunity together with vascular inflammation and endothelial dysfunction play a major role. Our observations, although limited due to the small sample size, suggest that there are unique features in the bone marrow of patients with MIS-C that are likely secondary to immuno-dysregulation, and there are notable differences in bone marrow features compared to those reported in sHLH.
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Affiliation(s)
- Maria Antonietta De Ioris
- Department of Haematology/Oncology, Cell and, Gene TherapyBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Alessia Scarselli
- Pediatric Unit, Pediatric Emergency Department (DEA)Bambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Claudia Bracaglia
- Division of Rheumatology and Laboratory of ImmunoRheumatologyBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Daniela Perrotta
- Department of Anesthesia and Critical CareBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Stefania Bernardi
- Pediatric Academic DepartmentBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Veronica Santilli
- Pediatric Academic DepartmentBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Giulia Ceglie
- Department of Haematology/Oncology, Cell and, Gene TherapyBambino Gesù Children's Hospital, IRCCSRomeItaly,University of Tor VergataRomeItaly
| | - Francesco Fabozzi
- Department of Haematology/Oncology, Cell and, Gene TherapyBambino Gesù Children's Hospital, IRCCSRomeItaly,University of Tor VergataRomeItaly
| | - Chiara Agrati
- Cellular Immunology LaboratoryIRCCS National Institute for Infectious Diseases “L. Spallanzani”RomeItaly
| | - Giusi Prencipe
- Division of Rheumatology and Laboratory of ImmunoRheumatologyBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Rita Alaggio
- Department of PathologyBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Angela Mastronuzzi
- Department of Haematology/Oncology, Cell and, Gene TherapyBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Rita De Vito
- Department of PathologyBambino Gesù Children's Hospital, IRCCSRomeItaly
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10
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Muacevic A, Adler JR, Markofski M, Dao K, Shaw E, Odum C, Parisio-Poldiak N, Finer A, Flynn M. Utility of the HScore for Predicting COVID-19 Severity. Cureus 2022; 14:e31969. [PMID: 36589196 PMCID: PMC9795835 DOI: 10.7759/cureus.31969] [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: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cytokine release syndrome is a life-threatening condition known to cause fever and multiple organ dysfunction and is suspected to be related to the severity of coronavirus disease 2019 (COVID-19). We sought to examine the utility of the HScore and non-cytokine markers of inflammation for predicting COVID-19 outcomes. We hypothesized that cytokine storm, assessed by a modified HScore, would be linked to more severe COVID-19 symptoms and higher mortality. METHODS A retrospective review of records from a large, private hospital system was conducted on patients with hemophagocytic lymphohistiocytosis (HLH) (2014-2019) and compared to a large cohort of COVID-19-positive patients (2020). Patients with a sufficient number of elements in their record for a modified HScore calculation (n=4663), were further subdivided into population 1 (POP1, n=67; HLH, n=493 COVID-19), which had eight HScore elements, and population 2 (POP2) with six available HScore elements (POP2, n=102; HLH, n=4561 COVID-19). RESULTS Modified HScore predicted COVID-19 severity in POP1 and POP2 as measured by higher odds of being on a ventilator (POP2 OR: 1.46, CI: 1.42-1.5), ICU admission (POP2 OR: 1.38, CI: 1.34-1.42), a longer length of stay (p<0.0001), and higher mortality (POP2 OR: 1.34, CI: 1.31-1.39). C-reactive protein (CRP) and white blood cell (WBC) count were the most consistent non-cytokine predictors of COVID-19 severity. CONCLUSION Cytokine storm, evaluated using a modified HScore, appeared to play a role in the severity of COVID-19 infection, and selected non-cytokine markers of inflammation were predictive of disease severity.
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11
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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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12
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Liu JM, Chi J. Is COVID-19-associated cytokine storm distinct from non-COVID-19 secondary hemophagocytic lymphohistiocytosis? Exp Biol Med (Maywood) 2022; 247:330-337. [PMID: 35068219 PMCID: PMC8899343 DOI: 10.1177/15353702211068840] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Cytokine storm is an umbrella term that describes an inflammatory syndrome characterized by elevated levels of circulating cytokines and hyperactivation of innate and/or adaptive immune cells. One type of cytokine storm is hemophagocytic lymphohistiocytosis (HLH), which can be either primary or secondary. Severe COVID-19-associated pneumonia and acute respiratory distress syndrome (ARDS) can also lead to cytokine storm/cytokine release syndrome (CS/CRS) and, more rarely, meet criteria for the diagnosis of secondary HLH. Here, we review the immunobiology of primary and secondary HLH and examine whether COVID-19-associated CS/CRS can be discriminated from non-COVID-19 secondary HLH. Finally, we review differences in immunobiology between these different entities, which may inform both clinical diagnosis and treatment of patients.
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Affiliation(s)
- Johnson M Liu
- Division of Hematology, Department of Medicine, Maine Medical Center, Portland, ME 04102, USA
| | - Jeffrey Chi
- Division of Hematology-Oncology, Department of Medicine, Monter Cancer Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY 11042, USA
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13
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Koumadoraki E, Madouros N, Sharif S, Saleem A, Jarvis S, Khan S. Hemophagocytic Lymphohistiocytosis and Infection: A Literature Review. Cureus 2022; 14:e22411. [PMID: 35345677 PMCID: PMC8942143 DOI: 10.7759/cureus.22411] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/19/2022] [Indexed: 11/21/2022] Open
Abstract
Hemophagocytic lymphocytosis (HLH) is a life-threatening, underdiagnosed syndrome caused by the excessive release of inflammatory mediators. Primary lymphocytosis is usually seen in young children and is associated with genetic defects, while secondary lymphocytosis is presented in adults due to malignancy, rheumatic disease, or infection. The aim of this study is to describe the infectious agents that trigger HLH in the adult population and provide diagnostic and treatment guidelines for this life-threatening syndrome. We conducted a literature review using PubMed as our basic database. We collected papers from the past six years that studied infectious agents that triggered HLH and described the most recommended treatment options for this serious condition. A total of 32 studies were included for this literature review.HLH is considered a syndrome with variable symptoms, and clinicians should be familiar with its complexity and the pathologies that could contribute to its presentation. Collaboration between physicians and awareness are basic steps for the management of patients with HLH.
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Affiliation(s)
- Evgenia Koumadoraki
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nikolaos Madouros
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shayka Sharif
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amber Saleem
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sommer Jarvis
- Anatomy/Cell Biology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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14
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A Rare STXBP2 Mutation in Severe COVID-19 and Secondary Cytokine Storm Syndrome. Life (Basel) 2022; 12:life12020149. [PMID: 35207437 PMCID: PMC8877603 DOI: 10.3390/life12020149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Primary (familial) hemophagocytic lymphohistiocytosis (pHLH) is a potentially lethal syndrome of infancy, caused by genetic defects in natural killer (NK) cell and CD8 T cell cytotoxicity, leading to hyperinflammation, elevated cytokine levels, and a disorganized immune response resulting in multi-organ system failure and frequently death. Secondary HLH (sHLH) can be triggered in the setting of malignances, diseases of chronic immune system activation, or by infectious etiologies. While pHLH is usually a result of homozygous gene mutations, monoallelic hypomorphic and dominant-negative mutations in pHLH genes have been implicated in sHLH. Coronavirus disease 2019 (COVID-19) has been an omnipresent viral infection since its arrival, and severe cases can present with cytokine storm and have clinical features and laboratory findings consistent with sHLH. Herein, we report an adolescent with severe COVID-19, decreased NK cell function, and features of sHLH. Her genetic evaluation identified a monoallelic missense mutation in the pHLH gene STXBP2, and NK cell assays of her blood showed decreased cytolysis and degranulation ex vivo. Methods: Patient data was extracted through an electronic medical record review. Using a lentiviral approach, the patient’s STXBP2 mutation and wild-type (WT) STXBP2 were separately transduced into the NK-92 human NK cell line. The WT and mutant STXBP2 transduced NK-92 cells were stimulated with NK-sensitive K562 erythroleukemia target cells in vitro, and NK cell degranulation and cytolysis were measured via CD107a expression and Live/Dead near-IR dye, respectively. Results: Compared to WT STXBP2, the patient’s STXBP2 mutation caused significantly decreased NK cell cytolysis and associated degranulation in vitro. Conclusion: These findings add weight to the hypothesis that some severe cases of COVID-19 may be accompanied by sHLH and hyperinflammation, especially in the setting of heterozygous pHLH genetic mutations. This has implications both diagnostically and therapeutically for severe COVID-19.
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15
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Dandu H, Yadav G, Malhotra HS, Pandey S, Sachu R, Dubey K. Hemophagocytic histiocytosis in severe SARS-CoV-2 infection: A bone marrow study. Int J Lab Hematol 2021; 43:1291-1301. [PMID: 34086418 PMCID: PMC8239926 DOI: 10.1111/ijlh.13619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The clinical and laboratory features of severe COVID-19 infection overlap with those of hemophagocytic lymphohistiocytosis (HLH), a hyperinflammatory disorder often associated with several viral infections. The clinical syndrome of HLH encompasses fever, organomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, raised transaminases, hypofibrinogenemia, absent natural killer (NK) cell activity, increased soluble CD25 and hemophagocytic lymphohistiocytosis in bone marrow, spleen, and lymph nodes. METHODS We analyzed clinicopathological and laboratory features of thirteen patients with severe COVID-19 infection suspected to have HLH and found to have hemophagocytic histiocytosis on bone marrow examination (BME). RESULTS Five of thirteen (38.46%) patients fulfilled five of eight HLH 2004 criteria and/or had a H-score ≥169. Three (23.08%) satisfied four of eight and remainder five (38.46%) satisfied three of eight HLH 2004 criteria. Fever, raised serum ferritin (13/13, 100%), transaminases (9/13, 69.23%), triglycerides (4/13, 30.76%), cytopenias (5/13, 38.46%), hypofibrinogenemia (2/13, 15.38%), and organomegaly (1/13, 7.69%) were observed in our patients. BME showed hemophagocytic histiocytosis without lymphocytosis in all. Contrary to HLH, lymphocytopenia (11/13, 84.61%), leukocytosis (7/13, 53.84%), neutrophilia (7/13, 53.84%), and hyperfibrinogenemia (7/13, 53.84%) were observed. Serum CRP, LDH, and plasma D-dimer were elevated in all, while serum albumin was decreased in 12 of 13 (92.3%) patients. Five patients recovered with high-dose pulsed corticosteroid therapy. CONCLUSION The immune response associated with severe COVID-19 infection is similar to HLH with few differences. HLH should be suspected in severe COVID-19 infection although all patients may not fulfill required HLH diagnostic criteria. BME should be done in suspected cases so that appropriate therapy may be initiated early.
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Affiliation(s)
- Himanshu Dandu
- Department of Internal MedicineKing George’s Medical UniversityLucknowIndia
| | - Geeta Yadav
- Department of PathologyKing George’s Medical UniversityLucknowIndia
| | | | - Saurabh Pandey
- Department of Internal MedicineKing George’s Medical UniversityLucknowIndia
| | - Ruovinuo Sachu
- Department of PathologyKing George’s Medical UniversityLucknowIndia
| | - Kinjalk Dubey
- Department of Internal MedicineKing George’s Medical UniversityLucknowIndia
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16
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Brescia-COVID Respiratory Severity Scale (BRCSS) and Quick SOFA (qSOFA) score are most useful in showing severity in COVID-19 patients. Sci Rep 2021; 11:21807. [PMID: 34750412 PMCID: PMC8575935 DOI: 10.1038/s41598-021-01181-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/28/2021] [Indexed: 12/27/2022] Open
Abstract
In this study, we compare the predictive value of clinical scoring systems that are already in use in patients with Coronavirus disease 2019 (COVID-19), including the Brescia-COVID Respiratory Severity Scale (BCRSS), Quick SOFA (qSOFA), Sequential Organ Failure Assessment (SOFA), Multilobular infiltration, hypo-Lymphocytosis, Bacterial coinfection, Smoking history, hyper-Tension, and Age (MuLBSTA) and scoring system for reactive hemophagocytic syndrome (HScore), for determining the severity of the disease. Our aim in this study is to determine which scoring system is most useful in determining disease severity and to guide clinicians. We classified the patients into two groups according to the stage of the disease (severe and non-severe) and adopted interim guidance of the World Health Organization. Severe cases were divided into a group of surviving patients and a deceased group according to the prognosis. According to admission values, the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore were evaluated at admission using the worst parameters available in the first 24 h. Of the 417 patients included in our study, 46 (11%) were in the severe group, while 371 (89%) were in the non-severe group. Of these 417 patients, 230 (55.2%) were men. The median (IQR) age of all patients was 44 (25) years. In multivariate logistic regression analyses, BRCSS in the highest tertile (HR 6.1, 95% CI 2.105–17.674, p = 0.001) was determined as an independent predictor of severe disease in cases of COVID-19. In multivariate analyses, qSOFA was also found to be an independent predictor of severe COVID-19 (HR 4.757, 95% CI 1.438–15.730, p = 0.011). The area under the curve (AUC) of the BRCSS, qSOFA, SOFA, MuLBSTA, and HScore was 0.977, 0.961, 0.958, 0.860, and 0.698, respectively. Calculation of the BRCSS and qSOFA at the time of hospital admission can predict critical clinical outcomes in patients with COVID-19, and their predictive value is superior to that of HScore, MuLBSTA, and SOFA. Our prediction is that early interventions for high-risk patients, with early identification of high-risk group using BRCSS and qSOFA, may improve clinical outcomes in COVID-19.
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17
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Kikuchi A, Singh K, Gars E, Ohgami RS. Pathology updates and diagnostic approaches to hemophagocytic lymphohistiocytosis. Histopathology 2021; 80:616-626. [PMID: 34716920 DOI: 10.1111/his.14591] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a complex, often under-recognized hyperinflammatory immune dysregulation syndrome arising in a diverse range of clinical scenarios and conditions. The accurate and timely diagnosis of HLH is crucial for patient survival, and usually requires a high level of clinical suspicion. The histologic corollary to clinical HLH - hemophagocytosis - is neither necessary nor sufficient for the diagnosis of HLH, as it may be seen in a variety of reactive conditions and may be absent in true HLH. Nevertheless, the finding of hemophagocytosis in specific clinical situations should prompt consideration of HLH and further testing to exclude the condition. While traditionally described in bone marrow, identification of hemophagocytosis in other tissues, including lymphoid, splenic, liver, or neural tissue, can be an important asset to the overall recognition of HLH. In this review we discuss the underlying pathophysiology and etiologies of HLH, morphologic aspects of hemophagocytosis and its associated histologic findings in different tissues, and give a brief overview of diagnostic criteria and clinical evaluation.
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Affiliation(s)
- Alexander Kikuchi
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Kunwar Singh
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Gars
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Robert S Ohgami
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
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18
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Bordbar M, Sanaei Dashti A, Amanati A, Shorafa E, Mansoori Y, Dehghani SJ, Molavi Vardanjani H. Assessment of the HScore as a predictor of disease outcome in patients with COVID-19. BMC Pulm Med 2021; 21:338. [PMID: 34715834 PMCID: PMC8555714 DOI: 10.1186/s12890-021-01706-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/25/2021] [Indexed: 12/02/2022] Open
Abstract
Severe coronavirus disease 2019 (COVID-19) accompanies hypercytokinemia, similar to secondary hemophagocytic lymphohistiocytosis (sHLH). We aimed to find if HScore could predict disease severity in COVID-19. HScore was calculated in hospitalized children and adult patients with a proven diagnosis of COVID-19. The need for intensive care unit (ICU), hospital length of stay (LOS), and in-hospital mortality were recorded. The median HScore was 43.0 (IQR 0.0–63.0), which was higher in those who needed ICU care (59.7, 95% CI 46.4–72.7) compared to those admitted to non-ICU medical wards (38.8, 95% CI 32.2–45.4; P = 0.003). It was also significantly higher in patients who died of COVID-19 (105.1, 95% CI 53.7–156.5) than individuals who survived (41.5, 95% CI 35.8–47.1; P = 0.005). Multivariable logistic regression analysis revealed that higher HScore was associated with a higher risk of ICU admission (adjusted OR = 4.93, 95% CI 1.5–16.17, P = 0.008). The risk of death increased by 20% for every ten units increase in HScore (adjusted OR 1.02, 95% CI 1.00–1.04, P = 0.009). Time to discharge was statistically longer in high HScore levels than low levels (HR = 0.41, 95% CI 0.24–0.69). HScore is much lower in patients with severe COVID-19 than sHLH. Higher HScore is associated with more ICU admission, more extended hospitalization, and a higher mortality rate. A modified HScore with a new cut-off seems more practical in predicting disease severity in patients with severe COVID-19.
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Affiliation(s)
| | - Anahita Sanaei Dashti
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Amanati
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Eslam Shorafa
- Pediatrics Department, Division of Intensive Care, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Yasaman Mansoori
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Hossein Molavi Vardanjani
- Research Center for Traditional Medicine and History of Medicine, School of Medicine, Shiraz University of Medical Sciences, Zand St., Shiraz, Iran.
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19
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Rad HS, Röhl J, Stylianou N, Allenby MC, Bazaz SR, Warkiani ME, Guimaraes FSF, Clifton VL, Kulasinghe A. The Effects of COVID-19 on the Placenta During Pregnancy. Front Immunol 2021; 12:743022. [PMID: 34603330 PMCID: PMC8479199 DOI: 10.3389/fimmu.2021.743022] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 12/21/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a global pandemic. The virus primarily affects the lungs where it induces respiratory distress syndrome ranging from mild to acute, however, there is a growing body of evidence supporting its negative effects on other system organs that also carry the ACE2 receptor, such as the placenta. The majority of newborns delivered from SARS-CoV-2 positive mothers test negative following delivery, suggesting that there are protective mechanisms within the placenta. There appears to be a higher incidence of pregnancy-related complications in SARS-CoV-2 positive mothers, such as miscarriage, restricted fetal growth, or still-birth. In this review, we discuss the pathobiology of COVID-19 maternal infection and the potential adverse effects associated with viral infection, and the possibility of transplacental transmission.
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Affiliation(s)
- Habib Sadeghi Rad
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Joan Röhl
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Nataly Stylianou
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Mark C Allenby
- School of Chemical Engineering, University of Queensland, St Lucia, QLD, Australia.,Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sajad Razavi Bazaz
- School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
| | - Majid E Warkiani
- School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Vicki L Clifton
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Arutha Kulasinghe
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.,The University of Queensland Diamantina Institute (UQDI), Brisbane, QLD, Australia
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20
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Pereira MAM, da Costa LMM, Nascimento SB, Kang HC, Gabriel AHD. Hemophagocytic lymphohistiocytosis in adults: A key issue in the COVID-19 era. CLINICAL INFECTION IN PRACTICE 2021; 12:100100. [PMID: 34549179 PMCID: PMC8447538 DOI: 10.1016/j.clinpr.2021.100100] [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: 07/20/2021] [Revised: 09/04/2021] [Accepted: 09/14/2021] [Indexed: 11/04/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by persistent activation of the mononuclear phagocytic system, systemic inflammation, and hypercytokinaemia, which can lead to liver failure, “sepsis-like syndrome” and ultimately, to multiple organ failure and death. These disorders can be divided into primary and secondary (or reactive), the first, also known as familial HLH, is a genetic condition of childhood, which affects the function of TCD8 and NK cells, and usually presents in the first year of life. The secondary HLH affects mainly adults and adolescents and, it's more related to dysregulation of the immune system. In face of the COVID-19 pandemic and several reports of HLH by SARS-CoV-2, it is necessary to discuss the pathophysiology of HLH in adults more clearly. Thus, we present, for the first time, a didactic approach using illustrations and tables, compiling the most recent and relevant information to better understand this entity.
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Affiliation(s)
- Miguel Augusto Martins Pereira
- Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil.,Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro, Brazil
| | | | | | - Hye Chung Kang
- Universidade Federal Fluminense, Departamento de Patologia, Niterói, Rio de Janeiro, Brazil
| | - Adelmo Henrique Daumas Gabriel
- Universidade Federal Fluminense, Departamento de Medicina Clínica, Niterói, Rio de Janeiro, Brazil.,Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
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21
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Abstract
PURPOSE OF REVIEW The COVID-19 pandemic is a global public health crisis with considerable mortality and morbidity. A role for cytokine storm and therapeutic immunomodulation in a subgroup of patients with severe COVID-19 was proposed early in the pandemic. The concept of cytokine storm in COVID-19 has been criticised, given the lack of clear definition and relatively modest cytokinaemia (which may be necessary for viral clearance) compared with acute respiratory distress syndrome and bacterial sepsis. Here we consider the arguments for and against the concept of cytokine storm in COVID-19. RECENT FINDINGS Several criteria have been proposed to identify the subgroup of COVID-19 patients exhibiting a cytokine storm. The beneficial effects of corticosteroids and interleukin-6 inhibition suggest that inflammation is a modifiable pathogenic component of severe COVID-19. The presence of genetic polymorphisms and pathogenic auto-autoantibodies in severe COVID-19 also suggests a significant contribution of immune dysregulation to poor outcomes. SUMMARY Hyperinflammation is a key component of severe COVID-19, residing underneath the cytokine storm umbrella term, associated with poor outcomes. Better understanding of the aetiopathogenesis, with identification of biomarkers to predict treatment responses and prognosis, will hopefully enable a stratified and ultimately precision medicine approach.
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Affiliation(s)
- Puja Mehta
- Centre for Inflammation and Tissue Repair, UCL Respiratory, Division of Medicine, University College London
- Department of Rheumatology, University College London Hospital (UCLH), London, UK
| | - David C. Fajgenbaum
- Department of Medicine, Division of Translational Medicine and Human Genetics, Center for Cytokine Storm Treatment and Laboratory, Philadelphia, Pennsylvania, USA
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22
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Hossein Kazemi M, Kuhestani Dehaghi B, Roshandel E, Bonakchi H, Parkhideh S, Mehdizadeh M, Hajifathali A. Association of HScore Parameters with Severe COVID-19: A Systematic Review and Meta-Analysis. IRANIAN JOURNAL OF MEDICAL SCIENCES 2021; 46:322-338. [PMID: 34539007 PMCID: PMC8438337 DOI: 10.30476/ijms.2021.88404.1910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/20/2020] [Accepted: 01/23/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Several reports have associated the severe Coronavirus disease-2019 (sCOVID-19) with secondary-hemophagocytic lymphohistiocytosis (sHLH) and proposed utilizing the hemophagocytic syndrome diagnostic score (HScore) for sCOVID-19 patients. We conducted a systematic review and meta-analysis to find the possible association of HScore parameters with severity in COVID-19 patients. METHODS A systematic search was performed in Medline via PubMed, EMBASE, and Cochrane databases using all HScore and COVID-19 keywords. The studies were all from 2020, and the study language was limited to English. The records were screened based on inclusion/exclusion criteria. Random/fixed-effect models were employed for meta-analysis, based on the I2 index of parameters. The pooled mean differences were estimated for continuous parameters. The pooled odds-ratio was estimated for fever. The level of significance was set at 0.05. RESULTS Eighteen studies (comprising 2459 patients) out of 26151 screened studies were included in this meta-analysis. The results showed that the level of leukocyte, neutrophil, aspartate transaminase (AST), ferritin, and fibrinogen were significantly higher in sCOVID-19 patients than in non-severe ones. Significant lower levels of lymphocyte, platelet, and hemoglobin were also found in sCOVID-19 patients than non-severe patients. Fever was nearly associated with two times increased odds of sCOVID-19 (P=0.051). CONCLUSION Lymphopenia, thrombocytopenia, hypohemoglobinemia, hyperferritinemia, high levels of AST, and fever are common features of both sCOVID-19 and HLH. However, the leukocytosis, neutrophilia, and hyperfibrinogenemia found in sCOVID-19 are in contrast with HScore. Conclusively, HScore parameters could be risk factors for sCOVID-19. However, some parameters' roles are contradictory, suggesting the need for further investigation and a new way of HScore interpretation in sCOVID-19 patients.A preprint of this study was published at https://www.researchsquare.com/article/rs-54490/v2.
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Affiliation(s)
- Mohammad Hossein Kazemi
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Bentolhoda Kuhestani Dehaghi
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Roshandel
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Bonakchi
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Biostatistics, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayeh Parkhideh
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Mehdizadeh
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Hajifathali
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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23
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Obuchowska A, Standyło A, Obuchowska K, Kimber-Trojnar Ż, Leszczyńska-Gorzelak B. Cytokine Storms in the Course of COVID-19 and Haemophagocytic Lymphohistiocytosis in Pregnant and Postpartum Women. Biomolecules 2021; 11:1202. [PMID: 34439868 PMCID: PMC8391528 DOI: 10.3390/biom11081202] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022] Open
Abstract
The term 'cytokine storm' (CS) applies to a pathological autoimmune reaction when the interactions that lead to cytokine production are destabilised and may even lead to death. CS may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we present our analysis of certain pathological processes that induce a CS in pregnant and postpartum women. We draw our attention to the similarities between the severe course of Coronavirus Disease 2019 (COVID-19) and haemophagocytic lymphohistiocytosis (HLH). It is noteworthy that many of the criteria used to diagnose HLH are described as COVID-19 mortality predictors. Cytokine storms are considered to be an important cause of death in patients with the severe course of SARS-CoV-2 infection. Due to the fact that pregnant women are in an immunosuppressive state, viral pulmonary infections are more perilous for them-possible risks include miscarriage, intrauterine growth restriction or birth before the term; sometimes ventilation support is needed. HLH should be considered in pregnant and puerperal women suffering from moderately severe to severe COVID-19 and presenting with: fever unresponsive to antibiotic therapy, cytopenia, hepatitis and hyperferritinaemia. The HLH disorder is rare and difficult to diagnose; however, its early detection could reduce patient mortality.
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Affiliation(s)
| | - Arkadiusz Standyło
- Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (A.O.); (K.O.); (Ż.K.-T.); (B.L.-G.)
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24
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Ramos-Casals M, Brito-Zerón P, Mariette X. Systemic and organ-specific immune-related manifestations of COVID-19. Nat Rev Rheumatol 2021; 17:315-332. [PMID: 33903743 PMCID: PMC8072739 DOI: 10.1038/s41584-021-00608-z] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 01/08/2023]
Abstract
Immune-related manifestations are increasingly recognized conditions in patients with COVID-19, with around 3,000 cases reported worldwide comprising more than 70 different systemic and organ-specific disorders. Although the inflammation caused by SARS-CoV-2 infection is predominantly centred on the respiratory system, some patients can develop an abnormal inflammatory reaction involving extrapulmonary tissues. The signs and symptoms associated with this excessive immune response are very diverse and can resemble some autoimmune or inflammatory diseases, with the clinical phenotype that is seemingly influenced by epidemiological factors such as age, sex or ethnicity. The severity of the manifestations is also very varied, ranging from benign and self-limiting features to life-threatening systemic syndromes. Little is known about the pathogenesis of these manifestations, and some tend to emerge within the first 2 weeks of SARS-CoV-2 infection, whereas others tend to appear in a late post-infectious stage or even in asymptomatic patients. As the body of evidence comprises predominantly case series and uncontrolled studies, diagnostic and therapeutic decision-making is unsurprisingly often based on the scarcely reported experience and expert opinion. Additional studies are required to learn about the mechanisms involved in the development of these manifestations and apply that knowledge to achieve early diagnosis and the most suitable therapy.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
- Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Pilar Brito-Zerón
- Department of Internal Medicine, Hospital CIMA-Sanitas, Barcelona, Spain
| | - Xavier Mariette
- Department of Rheumatology, Center for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Saclay, INSERM, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
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25
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Wood H, Kulasekararaj AG. Limited utility of the HScore in detecting secondary haemophagocytic lymphohistiocytosis in COVID-19: response. Br J Haematol 2021; 194:688-689. [PMID: 33993471 PMCID: PMC8239835 DOI: 10.1111/bjh.17535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Henry Wood
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital-NHS Foundation Trust, London, UK.,King's College London, London, UK.,NIHR/Wellcome King's Clinical Research Facility, London, UK
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26
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Sangha G, Kaushik K, Robinson A, Ainge T, Dungarwalla M, Chakraborty A. Limited utility of the HScore in detecting secondary haemophagocytic lymphohistiocytosis in COVID-19. Br J Haematol 2021; 194:686-688. [PMID: 33993500 DOI: 10.1111/bjh.17533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Gina Sangha
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Kunaal Kaushik
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Thomas Ainge
- Milton Keynes University Hospital, Milton Keynes, UK
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27
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Alhumaidan W, Al-Otaibi A, Elyamany G, Alabbas F, Ali TB. Familial hemophagocytic lymphohistiocytosis induced by SARS-CoV-2. Pediatr Hematol Oncol 2021; 38:406-409. [PMID: 33635161 DOI: 10.1080/08880018.2020.1867267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Wejdan Alhumaidan
- Department of Pediatrics, Division of Infectious Diseases, King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia
| | - Abdulnasir Al-Otaibi
- Department of Pediatrics, Division of Infectious Diseases, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ghaleb Elyamany
- Department of Central Military Laboratory and Blood Bank, Division of Hematology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fahad Alabbas
- Department of Pediatrics, Division of Hematology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Tahani Bin Ali
- Department of Pediatrics, Division of Hematology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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28
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Retamozo S, Brito-Zerón P, Sisó-Almirall A, Flores-Chávez A, Soto-Cárdenas MJ, Ramos-Casals M. Haemophagocytic syndrome and COVID-19. Clin Rheumatol 2021; 40:1233-1244. [PMID: 33389315 PMCID: PMC7778844 DOI: 10.1007/s10067-020-05569-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022]
Abstract
Primary and secondary haemophagocytic lymphohistiocytosis (HLH) are hyperferritinaemic hyperinflammatory syndromes with a common terminal pathway triggered by different etiopathogenetic factors. HLH is characterised by a decreased capacity of interferon gamma production with an activated NK phenotype profile similar to other hyperinflammatory syndromes. Viruses are closely linked to the development of HLH as infectious triggers, and the break of tolerance to self-antigens is considered a critical mechanism involved in the development of immune-mediated conditions triggered by viral infections. Emerging studies in patients with COVID-19 are suggesting a key role of monocytes/macrophages in the pathogenesis of this viral infection, and there is a significant overlap between several features reported in severe COVID-19 and the features included in the HLH-2004 diagnostic criteria. Therefore, SARS-Cov-2, as other respiratory viruses, may also be considered a potential etiological trigger of HLH. The frequency of HLH in adult patients with severe COVID-19 is lower than 5%, although this figure could be underestimated considering that most reported cases lacked information about some specific criteria (mainly the histopathological criteria and the measurement of NK cell function and sCD25 levels). Because HLH is a multi-organ syndrome, the diagnostic approach in a patient with severe COVID-19 in whom HLH is suspected must be carried out in a syndromic and holistic way, and not in the light of isolated clinical or laboratory features. In COVID-19 patients presenting with persistent high fever, progressive pancytopenia, and hepatosplenic involvement, together with the characteristic triad of laboratory abnormalities (hyperferritinaemia, hypertriglyceridaemia, and hypofibrinogenaemia), the suspicion of HLH is high, and the diagnostic workup must be completed with specific immunological and histopathological studies.
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Affiliation(s)
- Soledad Retamozo
- Instituto Modelo de Cardiología Privado S.R.L- Córdoba - Argentina, Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
| | - Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain
| | - Antoni Sisó-Almirall
- Grup Tranversal de Recerca en Atenció Primària, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre d'Atenció Primària Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerre (CAPSBE), Barcelona, Spain
| | | | - María-José Soto-Cárdenas
- Department of Internal Medicine, Hospital Universitario Puerta del Mar, Cádiz, University of Cadiz, Cadiz, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain.
- Department of Medicine, University of Barcelona, Barcelona, Spain.
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
- Servei de Malalties Autoimmunes Sistèmiques, Hospital Clínic, C/Villarroel, 170, 08036, Barcelona, Spain.
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29
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Tang KT, Hsu BC, Chen DY. Autoimmune and Rheumatic Manifestations Associated With COVID-19 in Adults: An Updated Systematic Review. Front Immunol 2021; 12:645013. [PMID: 33777042 PMCID: PMC7994612 DOI: 10.3389/fimmu.2021.645013] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/17/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Numerous cases of the coronavirus disease 2019 (COVID-19) with autoimmune and rheumatic manifestations have been reported. Despite the available reviews that summarized its autoimmune/rheumatic manifestations, a systematic approach is still lacking. Therefore, we conducted a comprehensive systematic review in order to give an overview upon these rare but clinically significant manifestations. Methods: We performed a literature search of PubMed and EMBASE as of October 9, 2020. All articles relevant to either systemic or organ-specific autoimmune and rheumatic manifestations potentially associated with COVID-19 were collected. The reviewed literature were limited to adults ≥18 years. Results: Although most of the existing evidence was based on case reports or case series without a long-term follow-up, a variety of autoimmune/rheumatic manifestations were associated with COVID-19. The manifestations that have a consistent association with COVID-19 include autoimmune cytopenia, cutaneous vasculitis, encephalitis, and Guillain-Barre syndrome. Such association is conflicting as regards to antiphospholipid syndrome, hemophagocytic lymphohistiocytosis, and myasthenia gravis. Conclusion: Our systematic review indicated the potential of the COVID-19 virus to trigger a myriad of autoimmune and rheumatic manifestations, which should be considered amid global efforts to combat COVID-19.
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Affiliation(s)
- Kuo-Tung Tang
- Division of Allergy, Immunology, and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Ph.D. Program in Translational Medicine and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Bo-Chueh Hsu
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital Puli Branch, Nantou, Taiwan
| | - Der-Yuan Chen
- Translational Medicine Laboratory, China Medical University Hospital, Taichung, Taiwan.,Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
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30
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von der Thüsen JH, van Bommel J, Kros JM, Verdijk RM, Lopuhaä B, Lam KH, Dik WA, Miedema JR. Case report: a fatal combination of hemophagocytic lymphohistiocytosis with extensive pulmonary microvascular damage in COVID-19 pneumonia. J Hematop 2021; 14:79-83. [PMID: 33110452 PMCID: PMC7581498 DOI: 10.1007/s12308-020-00423-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
The clinical features of COVID-19 have a considerable range from a mild illness to severe disease. Underlying pathophysiological mechanisms of the rapidly progressive, and often fatal, pulmonary disease frequently observed in COVID-19 need to be elucidated, in order to develop new treatment strategies for different disease endotypes. Fatal cases can display features of a cytokine storm, which may be related to hemophagocytic lymphohistiocytosis. Also, a spectrum of vascular changes, including microvascular damage, is known to accompany severe COVID-19. In this paper, we describe the co-occurrence of hemophagocytic lymphohistiocytosis and extensive pulmonary microvascular damage with thrombosis and its sequelae in a patient with fatal COVID-19. We believe these response patterns may be linked by common mechanisms involving hypercytokinemia and require further investigation as a fatal constellation in COVID-19, to generate appropriate treatment in patients who display these combined features.
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Affiliation(s)
- Jan H. von der Thüsen
- Department of Pathology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Jasper van Bommel
- Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands
| | - Johan M. Kros
- Department of Pathology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Robert M. Verdijk
- Department of Pathology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Boaz Lopuhaä
- Department of Pathology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - King H. Lam
- Department of Pathology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Willem A. Dik
- Department of Medical Immunology, Laboratory Medical Immunology, Erasmus MC, Rotterdam, The Netherlands
- Department of Internal Medicine, Section Clinical Immunology, Erasmus MC, Rotterdam, The Netherlands
| | - Jelle R. Miedema
- Department of Pulmonology, Erasmus MC, Rotterdam, The Netherlands
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31
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Kiss S, Gede N, Hegyi P, Németh D, Földi M, Dembrovszky F, Nagy B, Juhász MF, Ocskay K, Zádori N, Molnár Z, Párniczky A, Hegyi PJ, Szakács Z, Pár G, Erőss B, Alizadeh H. Early changes in laboratory parameters are predictors of mortality and ICU admission in patients with COVID-19: a systematic review and meta-analysis. Med Microbiol Immunol 2021; 210:33-47. [PMID: 33219397 PMCID: PMC7679241 DOI: 10.1007/s00430-020-00696-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/31/2020] [Indexed: 01/08/2023]
Abstract
Despite the growing knowledge of the clinicopathological features of COVID-19, the correlation between early changes in the laboratory parameters and the clinical outcomes of patients is not entirely understood. In this study, we aimed to assess the prognostic value of early laboratory parameters in COVID-19. We conducted a systematic review and meta-analysis based on the available literature in five databases. The last search was on July 26, 2020, with key terms related to COVID-19. Eligible studies contained original data of at least ten infected patients and reported on baseline laboratory parameters of patients. We calculated weighted mean differences (WMDs) for continuous outcomes and odds ratios (ORs) with 95% confidence intervals. 93 and 78 studies were included in quantitative and qualitative syntheses, respectively. Higher baseline total white blood cell count (WBC), C-reactive protein (CRP), lactate-dehydrogenase (LDH), creatine kinase (CK), D-dimer and lower absolute lymphocyte count (ALC) (WMDALC = - 0.35 × 109/L [CI - 0.43, - 0.27], p < 0.001, I2 = 94.2%; < 0.8 × 109/L, ORALC = 3.74 [CI 1.77, 7.92], p = 0.001, I2 = 65.5%) were all associated with higher mortality rate. On admission WBC, ALC, D-dimer, CRP, LDH, and CK changes could serve as alarming prognostic factors. The correct interpretation of laboratory abnormalities can guide therapeutic decisions, especially in early identification of potentially critical cases. This meta-analysis should help to allocate resources and save lives by enabling timely intervention.
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Affiliation(s)
- Szabolcs Kiss
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Dávid Németh
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Mária Földi
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Fanni Dembrovszky
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Bettina Nagy
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Márk Félix Juhász
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Noémi Zádori
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- Department of Anaesthesiology and Intensive Therapy, Poznan University for Medical Sciences, Poznan, Poland
| | - Andrea Párniczky
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- Heim Pál National Institute of Pediatrics, Budapest, Hungary
| | - Péter Jenő Hegyi
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Gabriella Pár
- Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Hussain Alizadeh
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary.
- First Department of Medicine, University of Szeged, Szeged, Hungary.
- Division of Hematology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary.
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32
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Swoboda J, Wittschieber D, Sanft J, Kleemann S, Elschner S, Ihle H, Hubig M, Pletz MW, Mall G, Gassler N. Bone marrow haemophagocytosis indicates severe infection with severe acute respiratory syndrome coronavirus 2. Histopathology 2020; 78:727-737. [PMID: 33067892 DOI: 10.1111/his.14281] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022]
Abstract
AIMS Haemophagocytosis in the bone marrow of patients who have succumbed to coronavirus disease 19 (COVID-19) has not been widely studied. The aims of the present study were to perform morphological analyses and morphometry of haemophagocytosis in the bone marrow of patients with severe COVID-19, and to correlate the findings with the clinical course of the disease. METHODS AND RESULTS In this single-centre study performed at the University Hospital Jena, bone marrow specimens of 15 deceased patients who had experienced a severe course of COVID-19 were sampled from the vertebral column during autopsy. Slides of the bone marrow were stained with routine stains or immunohistochemically, and further examined for haemophagocytosis by the use of light microscopy. To substantiate the morphological findings, additional slides were stained for CD163 and morphometry was performed. In all bone marrow samples, an increase in cellularity was found. Haemophagocytes with erythrophagocytosis were detected in 67% of the deceased patients. In tissues with low numbers of haemophagocytes or ill-defined haemophagocytes, an increase in iron deposits was frequently seen. Morphological findings were then correlated with several important clinical data, and the HScore (probability of having a reactive hemophagocytic syndrome) was calculated to posthumously confirm the diagnosis of secondary haemophagocytic lymphohistiocytosis. The median duration of disease and the hospitalisation time were lower in patients with haemophagocytosis (n = 10) than in patients without haemophagocytosis (n = 5). In addition, patients with haemophagocytes showed increased inflammatory parameters 2-5 days prior to death, in contrast to patients without haemophagocytes. CONCLUSIONS Haemophagocytosis is a common finding in the bone marrow of deceased individuals with severe COVID-19, and may indicate fatal severe acute respiratory syndrome coronavirus 2 infections.
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Affiliation(s)
- Julia Swoboda
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | | | - Juliane Sanft
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Sandra Kleemann
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Stefan Elschner
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Hannah Ihle
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Michael Hubig
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Gita Mall
- Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Nikolaus Gassler
- Section of Pathology, Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
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33
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Hueso T, Bouchez C, Salviat F, Foulon S, Albiges L, Bayle A, Gallois E, Vergé V, Boige V, Griscelli F, Pommeret F, Ghez D. Secondary haemophagocytic lymphohistiocytosis is a rare occurrence amongst cancer patients with COVID-19. Br J Haematol 2020; 192:e87-e90. [PMID: 33326597 DOI: 10.1111/bjh.17275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Thomas Hueso
- Hematology Department, Gustave Roussy Cancer Centre, Villejuif, France.,Paris-Sud University, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | | | - Flore Salviat
- Biostatistics Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - Stéphanie Foulon
- Biostatistics Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - Laurence Albiges
- Oncology Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - Arnaud Bayle
- Oncology Department, Gustave Roussy Cancer Centre, Villejuif, France
| | | | - Véronique Vergé
- Biology Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - Valérie Boige
- Oncology Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - Franck Griscelli
- Biology Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - Fanny Pommeret
- Oncology Department, Gustave Roussy Cancer Centre, Villejuif, France
| | - David Ghez
- Hematology Department, Gustave Roussy Cancer Centre, Villejuif, France
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34
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Lorenz G, Moog P, Bachmann Q, La Rosée P, Schneider H, Schlegl M, Spinner C, Heemann U, Schmid RM, Algül H, Lahmer T, Huber W, Schmaderer C. Title: Cytokine release syndrome is not usually caused by secondary hemophagocytic lymphohistiocytosis in a cohort of 19 critically ill COVID-19 patients. Sci Rep 2020; 10:18277. [PMID: 33106497 PMCID: PMC7589537 DOI: 10.1038/s41598-020-75260-w] [Citation(s) in RCA: 22] [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: 05/23/2020] [Accepted: 10/05/2020] [Indexed: 02/08/2023] Open
Abstract
Severe COVID-19 associated respiratory failure, poses the one challenge of our days. Assessment and treatment of COVID-19 associated hyperinflammation may be key to improve outcomes. It was speculated that in subgroups of patients secondary hemophagocytic lymphohistiocytosis (sHLH) or cytokine release syndrome (CRS) with features of macrophage activation syndrome might drive severe disease trajectories. If confirmed, profound immunosuppressive therapy would be a rationale treatment approach. Over a median observation period of 11 (IQR: 8; 16) days, 19 consecutive confirmed severe COVID-19-patients admitted to our intensive-care-unit were tested for presence of sHLH by two independent experts. HScores and 2004-HLH diagnostic criteria were assessed. Patients were grouped according to short-term clinical courses: discharge from ICU versus ongoing ARDS or death at time of analysis. The median HScore at admission was 157 (IQR: 98;180), without the key clinical triad of HLH, i.e. progressive cytopenia, persistent fever and organomegaly. Independent expert chart review revealed the absence of sHLH in all cases. No patient reached more than 3/6 of modified HLH 2004 criteria. Nevertheless, patients presented hyperinflammation with peripheral neutrophilic signatures (neutrophil/lymphocyte-ratio > 3.5). The latter best paralleled their short-term clinical courses, with declining relative neutrophil numbers prior to extubation (4.4, [IQR: 2.5;6.3]; n = 8) versus those with unfavourable courses (7.6, [IQR: 5.2;31], n = 9). Our study rules out virus induced sHLH as the leading cause of most severe-COVID-19 trajectories. Instead, an associated innate neutrophilic hyperinflammatory response or virus-associated-CRS appears dominant in patients with an unfavourable clinical course. Therapeutic implications are discussed.
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Affiliation(s)
- Georg Lorenz
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- School of Medicine, Klinikum rechts der Isar, Division of Rheumatology, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Philipp Moog
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- School of Medicine, Klinikum rechts der Isar, Division of Rheumatology, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Quirin Bachmann
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- School of Medicine, Klinikum rechts der Isar, Division of Rheumatology, Ismaninger Straße 22, 81675, Munich, Germany
| | - Paul La Rosée
- Clinic for Internal Medicine II, Schwarzwald-Baar Klinikum Villingen-Schwenningen, Klinikstr. 11, 78052, Villingen-Schwenningen, Germany
| | - Heike Schneider
- School of Medicine, Klinikum rechts der Isar, Department for Clinical Chemistry, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michaela Schlegl
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Spinner
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Uwe Heemann
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Roland M Schmid
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hana Algül
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Comprehensive Cancer Center Munich at the Klinikum rechts der Isar, Technische Universität München, 81675, Munich, Germany
| | - Tobias Lahmer
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Wolfgang Huber
- School of Medicine, Klinikum rechts der Isar, II. Department for Internal Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Schmaderer
- School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- German Center for Infectious Research (DZIF), Technische Universität München, 81675, Munich, Germany
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35
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Hakim NN, Chi J, Olazagasti C, Liu JM. Secondary hemophagocytic lymphohistiocytosis versus cytokine release syndrome in severe COVID-19 patients. Exp Biol Med (Maywood) 2020; 246:5-9. [PMID: 32972235 DOI: 10.1177/1535370220962043] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPACT STATEMENT Severe COVID-19 associated pneumonia and acute respiratory distress syndrome has recently been described with life-threatening features of cytokine storm and loosely referred to as hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS). Although a recent report indicated favorable responses to the interleukin-1 receptor antagonist, anakinra in eight patients with COVID-19 secondary HLH diagnosed using the HScore calculation, others have suggested that the diagnosis of secondary HLH is uncommon and that the use of the HScore has limited value in guiding immunomodulatory therapy for COVID-19. Here, we provide additional perspective on this important controversy based upon comparisons between 14 COVID-19 cytokine storm patients and 10 secondary HLH patients seen immediately prior to the pandemic. We hypothesize that identification of HLH may relate to the severity or timing of cytokine release and suggest distinguishing between cytokine release syndrome and secondary HLH, reserving the latter term for cases fulfilling diagnostic criteria.
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Affiliation(s)
- Nausheen N Hakim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Monter Cancer Center, Lake Success, NY 11042, USA
| | - Jeffrey Chi
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Monter Cancer Center, Lake Success, NY 11042, USA
| | - Coral Olazagasti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Monter Cancer Center, Lake Success, NY 11042, USA
| | - Johnson M Liu
- Division of Hematology, Department of Medicine, Maine Medical Center, Portland, ME 04102, USA
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36
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Fauter M, Viel S, Zaepfel S, Pradat P, Fiscus J, Villard M, Garnier L, Walzer T, Sève P, Henry T, Jamilloux Y. Low glycosylated ferritin is a sensitive biomarker of severe COVID-19. Cell Mol Immunol 2020; 17:1183-1185. [PMID: 32917980 PMCID: PMC7484604 DOI: 10.1038/s41423-020-00544-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 01/22/2023] Open
Affiliation(s)
- Maxime Fauter
- CIRI (International Centre for Research in Infectiology), Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France.,Department of Internal Medicine, University Hospital Croix-Rousse, Lyon 1 University, Lyon, France
| | - Sébastien Viel
- CIRI (International Centre for Research in Infectiology), Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France.,Immunology Laboratory, University Hospital Lyon Sud, Lyon 1 University, Lyon, France.,LIFE, Lyon Immunology Federation, Lyon, France
| | - Sabine Zaepfel
- Biochemistry Laboratory, University Hospital Croix-Rousse, Lyon 1 University, Lyon, France
| | - Pierre Pradat
- Centre for Clinical Research, University Hospital Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Julie Fiscus
- Biochemistry Laboratory, University Hospital Croix-Rousse, Lyon 1 University, Lyon, France
| | - Marine Villard
- Immunology Laboratory, University Hospital Lyon Sud, Lyon 1 University, Lyon, France
| | - Lorna Garnier
- Immunology Laboratory, University Hospital Lyon Sud, Lyon 1 University, Lyon, France
| | - Thierry Walzer
- CIRI (International Centre for Research in Infectiology), Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, University Hospital Croix-Rousse, Lyon 1 University, Lyon, France
| | - Thomas Henry
- CIRI (International Centre for Research in Infectiology), Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | - Yvan Jamilloux
- CIRI (International Centre for Research in Infectiology), Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France. .,Department of Internal Medicine, University Hospital Croix-Rousse, Lyon 1 University, Lyon, France. .,LIFE, Lyon Immunology Federation, Lyon, France.
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37
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Agbuduwe C, Basu S. Haematological manifestations of COVID-19: From cytopenia to coagulopathy. Eur J Haematol 2020; 105:540-546. [PMID: 32663356 PMCID: PMC7404736 DOI: 10.1111/ejh.13491] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023]
Abstract
Emerging data from the management of patients with coronavirus disease 2019 (COVID‐19) suggests multi‐systemic involvement, including the hemopoietic system. The haematological manifestations of COVID‐19 include blood count anomalies notably lymphopenia and neutrophilia which are of prognostic significance. Hyperferritinemia and elevated lactate dehydrogenase have also been associated with increased mortality. Furthermore, there is considerable evidence of a distinct coagulopathy associated with COVID‐19 characterised by elevated D‐dimers and an increased risk of thrombotic events. This comprehensive review summarises the latest evidence from published studies and discusses the implications of the various haematological manifestations of COVID‐19 with a view to guiding clinical management and risk stratification in this rapidly evolving pandemic.
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Affiliation(s)
| | - Supratik Basu
- University of Wolverhampton, Wolverhampton, UK.,New Cross Hospital, Wolverhampton, UK
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