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Nyvlt P, Schuster FS, Ihlow J, Heeren P, Spies C, Hiesgen J, Schenk T, von Brünneck AC, Westermann J, Brunkhorst FM, La Rosée P, Janka G, Lachmann C, Lachmann G. Value of hemophagocytosis in the diagnosis of hemophagocytic lymphohistiocytosis in critically ill patients. Eur J Haematol 2024; 112:917-926. [PMID: 38368850 DOI: 10.1111/ejh.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Ferritin is an established biomarker in the diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH), which is diagnosed by the HLH-2004 criteria. Among these criteria, detection of hemophagocytosis through invasive procedures may delay early life saving treatment. Our aim was to investigate the value of hemophagocytosis in diagnosing HLH in critically ill patients. METHODS In this secondary analysis of a retrospective observational study, we included all patients aged ≥18 years and admitted to any adult ICU at Charité-Universitätsmedizin Berlin between January 2006 and August 2018, who had hyperferritinemia (≥500 μg/L) and underwent bone marrow biopsy during their ICU course. RESULTS Two hundred fifty-two patients were included, of whom 31 (12.3%) showed hemophagocytosis. In multivariable logistic regression analysis, maximum ferritin was independently associated with hemophagocytosis. By removing hemophagocytosis from HLH-2004 criteria and HScore, prediction accuracy for HLH diagnosis was only marginally decreased compared to the original scores. CONCLUSIONS Our results strengthen the diagnostic value of ferritin and underline the importance of considering HLH diagnosis in patients with high ferritin but only four fulfilled HLH-2004 criteria, when hemophagocytosis was not assessed or not detectable. Proof of hemophagocytosis is not required for a reliable HLH diagnosis.
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Affiliation(s)
- Peter Nyvlt
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Friederike S Schuster
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Jana Ihlow
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pathology, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Patrick Heeren
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Claudia Spies
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Josephine Hiesgen
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Thomas Schenk
- Department of Hematology and Oncology, Universitätsklinikum Jena, Jena, Germany
| | - Ann-Christin von Brünneck
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pathology, Berlin, Germany
| | - Jörg Westermann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - Frank M Brunkhorst
- Center for Clinical Studies, Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Jena, Jena, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Schwarzwald-Baar-Klinikum, Villingen-Schwenningen, Germany
| | - Gritta Janka
- Clinic of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Cornelia Lachmann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gunnar Lachmann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, Berlin, Germany
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Fatma A, Raida BS, Mourad C, Ikram D, Zouheir B, Henda E. Performances of the H-score and the HLH-2004 score in the positive diagnosis of secondary hemophagocytic lymphohistiocytosis. Curr Res Transl Med 2024; 72:103430. [PMID: 38266400 DOI: 10.1016/j.retram.2023.103430] [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: 05/24/2023] [Revised: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphocytosis (HLH) is a rare clinical and biological entity that can be life-threatening. Early diagnosis can improve the overall prognosis of HLH. OBJECTIVES The aims of this study are to evaluate the performances of HLH-2004-score and H-score in identifying patients with secondary HLH and to determine an optimal H-score cut-off for our population. METHODS A retrospective study that involved all patients, with images of hemophagocytosis in myelograms analyzed at the laboratory of hematology, followed at these departments: clinical-hematology, internal-medicine, infectious-diseases and gastroenterology, University-Hospital "Hédi-Chaker", Sfax-Tunisia, (June2017-May2021). We identified two groups of patients: "HLH" and "Not-HLH". Then, for each patient, we calculated the HLH-2004-score and the H-score. RESULTS Forty-two patients were included in this study. Twenty-five (60 %) belonging to group "HLH" and seventeen (40 %) to group "Not-HLH" with a mean age (38.72 vs. 39.82 years, p = 0.846) respectively. The study of the performances demonstrated that H-score had better performances. The best cut-off value of H-score for our population was 158.5, allowing a gain in sensitivity (from 92 % to 96 %) compared to the original study cut-off of 169. CONCLUSION Both H-score and HLH-2004-score showed excellent discriminative powers with better performances for H-score. The new H-score cut-off at 158.5 can be applied to our population.
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Affiliation(s)
- Abida Fatma
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Ben Salah Raida
- Department of Internal Medicine, Hedi Chaker University Hospital, Sfax, Tunisia.
| | - Chaari Mourad
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Dammak Ikram
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Bahloul Zouheir
- Department of Internal Medicine, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Elleuch Henda
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
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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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Gopal A, Kim SJ. Hemophagocytic Lymphohistiocytosis in a Remote Kidney Transplant Recipient Triggered by HSV Infection With Complete Recovery: An Educational Case Report. Can J Kidney Health Dis 2024; 11:20543581241253921. [PMID: 38799982 PMCID: PMC11119350 DOI: 10.1177/20543581241253921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/15/2024] [Indexed: 05/29/2024] Open
Abstract
Rationale Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by excessive immune activation. It is more commonly seen in children but increasingly recognized in adults. Primary HLH relies on a genetic predisposition, whereas secondary HLH develops in the context of infections, malignancies, or autoimmune diseases. Hemophagocytic lymphohistiocytosis has been rarely described in patients on immunosuppressive therapy after kidney transplant. Here, we describe a case of HLH in a patient with a remote history of kidney transplant, triggered by a viral infection. Presenting Concerns A 45-year-old female, with a kidney transplant in 2009 for IgA nephropathy, presented with fever, vomiting, and back pain of 1-week duration. She was on triple immunosuppression consisting of daily doses of prednisone 5 mg, azathioprine 100 mg, and tacrolimus extended release 1 mg, and a baseline creatinine of 130 µmol/L. Diagnosis Initial investigations showed anemia, leukopenia, elevated serum creatinine, transaminitis, and markedly increased ferritin of 67 600 µg/L which prompted a bone marrow biopsy to rule out HLH. The bone marrow showed an increased proportion of CD68+ cells (macrophages) with more than 5 in 1000 hemophagocytic macrophages. Her soluble IL-2 receptor (CD25) level was 3406 pg/mL (606-2299 pg/mL) which was mildly elevated. She fulfilled 4 of the 8 criteria for HLH and with an H score was 223 which suggested a diagnosis of HLH with 96.9% probability. An extensive secondary workup for possible triggers for HLH led to a swab from genital ulcers that was positive for herpes simplex virus (HSV) type 2. The polymerase chain reaction (PCR) in the blood for HSV type 2 was also positive. Interventions Given the diagnosis of HSV type 2 as the putative trigger for HLH, she was started on parenteral acyclovir for 2 weeks followed by oral valacyclovir for 2 more weeks. In the context of infection, the azathioprine was stopped while low-dose steroid and tacrolimus were continued. Outcomes With the initiation of treatment for HSV infection, leukopenia, creatinine, and transaminases improved along with ferritin levels. At her 6-month follow-up, her blood counts and liver enzymes had normalized, and ferritin was 566 µg/L. Teaching points Hemophagocytic lymphohistiocytosis is a rare disease in kidney transplant recipients with a high mortality rate. It can occur even in remote kidney transplant recipients so a high degree of suspicion is necessary to lead to a prompt diagnosis. Infections are common triggers for secondary HLH. Early identification and treatment of the triggering infection may improve outcomes.
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Affiliation(s)
- Anjana Gopal
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - S. Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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See KC. Dengue-Associated Hemophagocytic Lymphohistiocytosis: A Narrative Review of Its Identification and Treatment. Pathogens 2024; 13:332. [PMID: 38668287 PMCID: PMC11053942 DOI: 10.3390/pathogens13040332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024] Open
Abstract
Dengue's lack of specific treatments beyond supportive care prompts a focus on uncovering additional pathophysiological factors. Dengue-associated hemophagocytic lymphohistiocytosis (HLH), characterized by dysregulated macrophage activation and cytokine storm, remains underexplored despite its potential to worsen disease severity and mortality. While rare, dengue-associated HLH disproportionately affects severe cases, significantly impacting mortality rates. To mitigate high mortality, early identification and familiarity with dengue-associated HLH are imperative for prompt treatment by clinicians. This narrative review therefore aims to examine the current clinical and therapeutic knowledge on dengue-associated HLH, and act as a resource for clinicians to improve their management of HLH associated with severe dengue. Dengue-associated HLH should be considered for all cases of severe dengue and may be suspected based on the presence of prolonged or recurrent fever for >7 days, or anemia without intravascular hemolysis or massive bleeding. Diagnosis relies on fulfilling at least five of the eight HLH-2004 criteria. Treatment predominantly involves short courses (3-4 days) of high-dose steroids (e.g., dexamethasone 10 mg/m2), with additional therapies considered in more severe presentations. Notably, outcomes can be favorable with steroid therapy alone.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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Orth HM, Wiemer D, Schneitler S, Schönfeld A, Holtfreter MC, Gliga S, Fuchs A, Pfäfflin F, Denkinger CM, Kalbitz S, Fritzsche C, Hübner MP, Trauth J, Jensen BEO, Luedde T, Feldt T. Hemophagocytic lymphohistiocytosis-how common and how severe is it as a complication of malaria? Retrospective case series and review of the literature. Infection 2024; 52:471-482. [PMID: 37875775 PMCID: PMC10955030 DOI: 10.1007/s15010-023-02104-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Infection-associated secondary hemophagocytic lymphohistiocytosis (sHLH) is a potentially life-threatening hyperinflammatory condition caused by various infectious diseases. Malaria has rarely been described as trigger. The aim of this study is to collect data on frequency, clinical spectrum, and outcome of sHLH induced by malaria. METHODS We collected case numbers on malaria and malaria-associated sHLH from specialized centers in Germany from 2015 to 2022. In addition, we conducted a literature search on published cases of malaria-associated sHLH and systematically analyzed the literature regarding clinical and diagnostic criteria. RESULTS We obtained data from 13 centers treating 1461 malaria cases with different Plasmodium species, of which 5 patients (0.34%) also were diagnosed with sHLH. The literature search revealed detailed case reports from further 51 patients and case series comprising the description of further 24 patients with malaria-associated sHLH. Most cases (48/80; 60%) were reported from Asia. The median time interval between onset of malaria symptoms and hospital admission was 7 days. Severe complications of sHLH were documented in 36% (20/56) of patients, including two patients with multiple organ failure in our case series. Only 41% (23/56) of patients received specific treatment for sHLH, nevertheless the mortality rate (CFR) of 5% is lower compared to the CFR reported for sHLH triggered by other infectious diseases (e.g., 25% in sHLH due to EBV infection). CONCLUSION Malaria-associated sHLH appears to have a comparatively good prognosis but may still represent an underdiagnosed and potentially fatal complication of malaria, especially in resource-poor settings.
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Affiliation(s)
- Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany.
| | - Dorothea Wiemer
- Department of Tropical Medicine and Infectious Diseases at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Sophie Schneitler
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Andreas Schönfeld
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Centre Essen, University of Duisburg-Essen DE, Essen, Germany
| | - Martha Charlotte Holtfreter
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Smaranda Gliga
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Andre Fuchs
- Internal Medicine III-Gastroenterology and Infectious Diseases, Augsburg University Hospital, Augsburg, Germany
| | - Frieder Pfäfflin
- Department for Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Claudia Maria Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | - Sven Kalbitz
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Carlos Fritzsche
- Department of Tropical Medicine and Infectious Diseases, Center for Internal Medicine, University of Rostock, Rostock, Germany
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Janina Trauth
- Division of Infectious Diseases, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Björn-Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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Xu S, He K. Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians. Transpl Immunol 2024; 83:102007. [PMID: 38307154 DOI: 10.1016/j.trim.2024.102007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.
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Affiliation(s)
- Shanshan Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China.
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Guo T, Liu Z, Chen Y, Cheng Y, He K, Lin X, Wang M, Sun Y. Hemophagocytic lymphohistiocytosis during treatment of intracranial multifocal germinoma: a case report and literature review. Front Oncol 2024; 14:1264926. [PMID: 38532931 PMCID: PMC10963405 DOI: 10.3389/fonc.2024.1264926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), also known as hemophagocytic syndrome (HPS), is a benign histiocytosis with hyperreactive proliferation of the mononuclear phagocyte system caused by immune function abnormalities, which often occurs under the background of genetic mutations, inflammation, infection or tumors. Because the research on malignancy-associated HLH (M-HLH) is focused on hematological malignancies, reports on HLH secondary to solid tumors are rare. In this case, we report a 14-year-old girl who developed HLH during treatment for intracranial multifocal germinoma, and the disease was controlled after hormone combined with etoposide(VP-16) and other related treatments. To our knowledge, there have been no documented cases of HLH caused by intracranial multifocal germinoma.
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Affiliation(s)
- Ting Guo
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Zichun Liu
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Yixin Chen
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yangyang Cheng
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Kaitong He
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Lin
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Mingzhu Wang
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yihua Sun
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
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Masood M, Siddique A, Krishnamoorthi R, Kozarek RA. Liver Dysfunction in Adult Hemophagocytic Lymphohistiocytosis: A Narrative Review. Adv Ther 2024; 41:553-566. [PMID: 38145441 DOI: 10.1007/s12325-023-02768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition that has been increasingly recognized in adults and is characterized by a hyperinflammatory state due to immune dysregulation. Its nonspecific presentation, the lack of clinician familiarity given its rarity, and shared clinical features with sepsis and other syndromes can lead to a delay in diagnosis and a poor prognosis. Significant liver function abnormalities as the initial manifestation of HLH are uncommon and can range from mild elevation of aminotransferases to fulminant hepatic failure with high mortality rates. The authors encountered a case of adult HLH mimicking acute viral hepatitis in which a markedly elevated ferritin level led to a prompt diagnosis, early initiation of treatment, and a successful outcome. Clinicians, including gastroenterologists and hepatologists, are often called upon to evaluate patients with abnormal liver tests and may lack experience in the early diagnosis and management of liver dysfunction in the context of HLH. Thus, we expand our reporting to a narrative review of literature which explores the pathogenesis of HLH, challenges associated with its diagnosis, previous reports of liver disease associated with the syndrome, recommended treatments for the familial and adult variations including the role of liver transplantation, and the outcomes of these treatments.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Asma Siddique
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA.
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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Jongdee P, Julamanee J, Rattarittamrong E, Mukura S, Wanitpongpun C, Deoisares R, Surawong A, Chajuwan T, Chanswangphuwana C. Prognostic Factors of Adult Hemophagocytic Lymphohistiocytosis and Clinical Utility of HLH-2004 Diagnostic Criteria and HScore: A Real-World Multicenter Study from Thailand. Acta Haematol 2024; 147:447-456. [PMID: 38262370 DOI: 10.1159/000536287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Adult hemophagocytic lymphohistiocytosis (HLH) is a rare disease with a dismal prognosis. Early diagnosis and prompt management are necessary for improved outcomes. METHODS This multicenter retrospective study investigated the etiologies, survival, and prognostic factors of HLH, including the utility of HLH-2004 criteria and HScore in real-life clinical practice. RESULTS A total of 147 HLH patients were identified by using a combination of hemophagocytosis identification in bone marrow and the HLH-related international classification disease-10. A total of 116 (78.9%) patients fulfilled the HLH diagnosis by HScore, while 91 (61.9%) patients fulfilled 5 of 8 HLH-2004 criteria. In Thailand, the clinical application of HLH-2004 criteria needed to be reduced from 8 to 6 due to a lack of sCD25 and natural killer cell activity tests. Using the adapted HLH-2004 with a cutoff value of 4 resulted in 132 (89.9%) cases meeting the diagnostic criteria. Among these 132 confirmed HLH patients by using adapted HLH-2004, HLH was triggered by infection (29.5%), autoimmune disease (12.9%), malignancy (40.9%), and unknown cause (16.7%). Median overall survival of HLH patients was extremely short (67 days). Ferritin >6,000 μg/L, HLH from infection, malignancy, and unknown etiology were demonstrated as independent prognostic factors for inferior survival (hazard ratio [HR] 2.47; 95% confidence interval [CI] 1.39-4.37, HR 4.69; 95% CI 1.38-15.92, HR 6.09; 95% CI 1.84-20.14, and HR 6.02; 95% CI 1.64-22.05, respectively). CONCLUSION Ferritin is a helpful biomarker for HLH diagnosis and prognostic prediction. Autoimmune disease-triggered HLH has favorable outcomes. Future prospective study is required to verify the use of the adapted HLH-2004 criteria.
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Affiliation(s)
- Pitchayaporn Jongdee
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jakrawadee Julamanee
- Hematology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ekarat Rattarittamrong
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sarita Mukura
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chinadol Wanitpongpun
- Hematology Unit, Department of Internal Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Rawisut Deoisares
- Department of Internal Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Anoree Surawong
- Department of Medicine, Sunprasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Thunyamon Chajuwan
- Department of Medicine, Sunprasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Chantiya Chanswangphuwana
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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11
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Rosado FG, Gopal P. Laboratory Features and Pathology of Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:43-58. [PMID: 39117807 DOI: 10.1007/978-3-031-59815-9_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
The laboratory diagnosis of cytokine storm syndromes (CSSs), i.e., hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS), is often challenging. The laboratory features using routinely available tests lack specificity, whereas confirmatory testing is available in only few laboratories in the United States. The disease mechanisms are still largely unclear, particularly in adults. In this chapter, the pathogenesis of CSSs, their associated laboratory findings, and recommended diagnostic strategies are reviewed.
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Affiliation(s)
- Flavia G Rosado
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Purva Gopal
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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12
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Bloch C, Jais JP, Gil M, Boubaya M, Lepelletier Y, Bader-Meunier B, Mahlaoui N, Garcelon N, Lambotte O, Launay D, Larroche C, Lazaro E, Liffermann F, Lortholary O, Michel M, Michot JM, Morel P, Cheminant M, Suarez F, Terriou L, Urbanski G, Viallard JF, Alcais A, Fischer A, de Saint Basile G, Hermine O. Severe adult hemophagocytic lymphohistiocytosis (HLHa) correlates with HLH-related gene variants. J Allergy Clin Immunol 2024; 153:256-264. [PMID: 37678575 DOI: 10.1016/j.jaci.2023.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/14/2023] [Accepted: 07/14/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND The contribution of genetic factors to the severity of adult hemophagocytic lymphohistiocytosis (HLHa) remains unclear. OBJECTIVE We sought to assess a potential link between HLHa outcomes and HLH-related gene variants. METHODS Clinical characteristics of 130 HLHa patients (age ≥ 18 years and HScore ≥ 169) and genotype of 8 HLH-related genes (LYST, PRF1, UNC13-D, STX11, STXBP2, RAB27A, XIAP, and SAP) were collected. A total of 34 variants found in only 6 genes were selected on the basis of their frequency and criteria predicted to impair protein function. Severity was defined by refractory disease to HLH treatment, death, or transfer to an intensive care unit. RESULTS HLHa-associated diseases (ADs) were neoplasia (n = 49 [37.7%]), autoimmune/inflammatory disease (n = 33 [25.4%]), or idiopathic when no AD was identified (n = 48 [36.9%]). Infectious events occurred in 76 (58.5%) patients and were equally distributed in all ADs. Severe and refractory HLHa were observed in 80 (61.5%) and 64 (49.2%) patients, respectively. HScore, age, sex ratio, AD, and infectious events showed no significant association with HLHa severity. Variants were identified in 71 alleles and were present in 56 (43.1%) patients. They were distributed as follows: 44 (34.4%), 9 (6.9%), and 3 (2.3%) patients carrying 1, 2, and 3 variant alleles, respectively. In a logistic regression model, only the number of variants was significantly associated with HLHa severity (1 vs 0: 3.86 [1.73-9.14], P = .0008; 2-3 vs 0: 29.4 [3.62-3810], P = .0002) and refractoriness (1 vs 0: 2.47 [1.17-5.34], P = .018; 2-3 vs 0: 13.2 [2.91-126.8], P = .0003). CONCLUSIONS HLH-related gene variants may be key components to the severity and refractoriness of HLHa.
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Affiliation(s)
- Coralie Bloch
- Clinical Research Unit, Avicenne University Hospital, AP-HP, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, Paris, France; Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France.
| | - Jean Philippe Jais
- Imagine Institute, Université Paris Cité, Paris, France; Biostatistic Unit, Necker University Hospital, AP-HP, Paris, France; Human Genetics of Infectious Diseases: Complex Predisposition, INSERM UMR1163, Paris, France
| | - Marine Gil
- Imagine Institute, Université Paris Cité, Paris, France
| | - Marouane Boubaya
- Clinical Research Unit, Avicenne University Hospital, AP-HP, Bobigny, France
| | - Yves Lepelletier
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; Imagine Institute, Université Paris Cité, Paris, France
| | - Brigitte Bader-Meunier
- Imagine Institute, Université Paris Cité, Paris, France; Department of Pediatric Immunology and Rheumatology, Necker University Hospital, AP-HP, Paris, France
| | - Nizar Mahlaoui
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Department of Pediatric Immunology and Rheumatology, Necker University Hospital, AP-HP, Paris, France
| | | | - Olivier Lambotte
- University Paris Saclay, AP-HP, Hôpital Bicêtre, IMVAHB UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - David Launay
- Université de Lille, CHU Lille, Département de Médecine Interne et Immunologie Clinique, Centre de Référence des Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France, Lille, France; INSERM INFINITE U1286, Lille, France
| | - Claire Larroche
- Internal Medicine Unit, Avicenne Hospital, AP-HP, Bobigny, France
| | - Estibaliz Lazaro
- Internal Medicine Department, Bordeaux Hospital University, Bordeaux, France; CNRS-UMR 5164 Immuno ConcEpT, Bordeaux, France
| | - Francois Liffermann
- Service de medecine interne-hematologie, Centre hospitalier de Dax, Dax, France
| | - Olivier Lortholary
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Service de Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker Pasteur, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Marc Michel
- Department of Internal Medicine, Centre de Référence maladies rares sur les Cytopénies Auto-Immunes de l'adulte, Hôpitaux Universitaires Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Jean-Marie Michot
- Gustave Roussy, University Paris Saclay, Drug Development Department, Villejuif, France
| | - Pierre Morel
- Service d'Hématologie Clinique, Hôpital Schaffner de Lens, Lens Cedex, France
| | - Morgane Cheminant
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Clinical Hematology, Necker University Hospital, AP-HP, Paris, France
| | - Felipe Suarez
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Clinical Hematology, Necker University Hospital, AP-HP, Paris, France
| | - Louis Terriou
- Université de Lille, CHU Lille, Département de Médecine Interne et Immunologie Clinique, Centre de Référence des Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France, Lille, France; INSERM INFINITE U1286, Lille, France
| | - Geoffrey Urbanski
- Department of Internal Medicine and Clinical Immunology, University Hospital, Angers, France; MitoLab Team, MITOVASC Institute, UMR CNRS 6015, INSERM U1083, University of Angers, Angers, France
| | | | - Alexandre Alcais
- Imagine Institute, Université Paris Cité, Paris, France; Biostatistic Unit, Necker University Hospital, AP-HP, Paris, France; Human Genetics of Infectious Diseases: Complex Predisposition, INSERM UMR1163, Paris, France
| | - Alain Fischer
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Department of Pediatric Immunology and Rheumatology, Necker University Hospital, AP-HP, Paris, France; Laboratory of Normal and Pathological Homeostasis of the Immune System, INSERM UMR1163, Paris, France; Necker University Hospital, AP-HP, Paris, France; College de France, Paris, France
| | - Geneviève de Saint Basile
- French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Laboratory of Normal and Pathological Homeostasis of the Immune System, INSERM UMR1163, Paris, France
| | - Olivier Hermine
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, INSERM UMR1163/CNRS URL 8254, Paris, France; French National Center for Primary Immunodeficiencies, Necker University Hospital, AP-HP, Paris, France; Imagine Institute, Université Paris Cité, Paris, France; Clinical Hematology, Necker University Hospital, AP-HP, Paris, France.
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13
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Chen QT, Chen MH, Lin YK, Yeh RH, Lu CC, Hsiao PJ, Sung YF. Case report: Hemophagocytic lymphohistiocytosis complicated by multiple organ dysfunction syndrome following aseptic encephalitis. Front Immunol 2023; 14:1296575. [PMID: 38193074 PMCID: PMC10773876 DOI: 10.3389/fimmu.2023.1296575] [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: 10/10/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially life-threatening condition caused by excessive immune activation. Secondary HLH is usually triggered by infection, most often from viral infection or malignancy. Here, we present a case of secondary HLH, complicated by multiple organ dysfunction syndrome triggered by critical aseptic encephalitis. A 27-year-old man without any underlying disease presented to our hospital with fever, disturbance of consciousness, and generalized seizures. The patient was diagnosed with aseptic encephalitis with super-refractory status epilepticus. Although antiseizure medications and immunoglobulins were administered, the patient developed multiple organ dysfunction syndrome. HLH was later diagnosed based on hypertriglyceridemia, hyperferritinemia, splenomegaly, cytopenia, and phagocytosis of nucleated cells, as shown by a blood smear of bone marrow aspiration. Treatment with pulse steroid therapy and plasmapheresis was initiated rather than chemotherapy because of the patient's critical condition. However, the patient died of profound shock and multiple organ failure. Diagnosis of HLH is challenging in patients with severe infections because of similar clinical manifestations and laboratory findings. The early recognition of HLH provides patients with the opportunity to receive appropriate treatment, which can lead to increased survival and remission rates.
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Affiliation(s)
- Quan-Ting Chen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Ming-Hua Chen
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yu-Kai Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ren-Hua Yeh
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Chi Lu
- Division of Rheumatology/Immunology and Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Hsiao
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yueh-Feng Sung
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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14
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Agyeman WY, Waitimu S, Seffah KD, Allihien SM, Soleye S. The Decimating Army: Hemophagocytic Lymphohistiocytosis as the Initial Presentation of Adult-Onset Still's Disease. Cureus 2023; 15:e43875. [PMID: 37746424 PMCID: PMC10511301 DOI: 10.7759/cureus.43875] [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: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and often missed presentation in the hospital setting. It is a hyperinflammatory syndrome of immune activation and dysregulation characterized by fever, cytopenias, elevated serum ferritin levels, and hepatosplenomegaly. It has a multifactorial etiology occurring primarily secondary to infection, malignancy, immune checkpoint inhibitors, or autoimmune disease. HLH that occurs in autoimmune diseases such as adult-onset Still's disease and systemic lupus erythematosus is referred to as macrophage activation syndrome. However, it may rarely be a primary disorder from a genetic defect. The pathophysiology of HLH is poorly understood and often results in multiorgan dysfunction. We present an older adult male patient with several hospital stays due to his symptoms, who presented with lethargy, low-grade fever, cough, dyspnea, and recurrent pleural effusions. He had bicytopenia, elevated ferritin, and hypertriglyceridemia. The diagnosis of HLH may be delayed, especially in older adult patients with an insidious course, and requires a high index of suspicion.
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Affiliation(s)
- Walter Y Agyeman
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Susan Waitimu
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Kofi D Seffah
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | | | - Saheed Soleye
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
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15
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Li X, Yan H, Xiao Z, Luo T, Xie L, Yang Y, Gong L, Tang Z, Tang M, Huang J, Zhang X, Zheng M, Yao Z, Zang P, Zhu D, Lu X. A Three-Step Screening Procedure for Early Identification of Children at High Risk of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2023; 43:989-998. [PMID: 36877313 DOI: 10.1007/s10875-023-01458-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The first step in diagnosing hemophagocytic lymphohistiocytosis (HLH) is to suspect its presence and then order the appropriate diagnostic tests. The development of screening procedures for HLH could facilitate early diagnosis. In this study, we evaluated the utility of fever, splenomegaly, and cytopenias as screening criteria for identifying pediatric HLH at an early stage, built a screening model using commonly measured laboratory parameters, and developed a step-wise screening procedure for pediatric HLH. METHODS The medical records of 83,965 pediatric inpatients, including 160 patients with HLH, were collected retrospectively. The utility of fever, splenomegaly, hemoglobin level, and platelet and neutrophil counts at hospital admission as screening criteria for HLH was evaluated. For HLH patients who might be missed by screening based on the presence of fever, splenomegaly, and cytopenias, a screening model using common laboratory parameters was developed. Following that, a three-step screening procedure was then developed. RESULTS The criteria of cytopenias affecting two or more lineages plus fever or splenomegaly had a sensitivity of 51.9% and a specificity of 98.4% for identifying HLH in pediatric inpatients. Our screening score model comprises six parameters: splenomegaly, platelet count, neutrophil count, albumin level, total bile acid level, and lactate dehydrogenase level. The use of the validation set had a sensitivity of 87.0% and a specificity of 90.6%. A three-step screening procedure has been developed: Step 1: Is fever or splenomegaly present? (Yes: risk for HLH should be considered, go to Step 2; No: less likely HLH); Step 2: Are cytopenias affecting at least two lineages? (Yes: consider HLH; No: go to Step 3); Step 3: Calculate the screening score. Is the sum of the score greater than 37? (Yes: consider HLH; No: less likely HLH). The overall sensitivity and specificity of the three-step screening procedure were 91.9% and 94.4%, respectively. CONCLUSION A significant proportion of pediatric HLH patients present at the hospital without having all three symptoms: fever, splenomegaly, and cytopenias. Our three-step screening procedure, utilizing commonly available clinical and laboratory parameters, can effectively identify pediatric patients who may be at high risk for HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ting Luo
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Longlong Xie
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Yufan Yang
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ling Gong
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Zhexuan Tang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Minghui Tang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children's Hospital, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China.
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16
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Diagnosing Hemophagocytic Lymphohistiocytosis with Machine Learning: A Proof of Concept. J Clin Med 2022; 11:jcm11206219. [PMID: 36294539 PMCID: PMC9605669 DOI: 10.3390/jcm11206219] [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: 09/27/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome characterized by uncontrolled activation of immune cells and mediators. Two diagnostic tools are widely used in clinical practice: the HLH-2004 criteria and the Hscore. Despite their good diagnostic performance, these scores were constructed after a selection of variables based on expert consensus. We propose here a machine learning approach to build a classification model for HLH in a cohort of patients selected by glycosylated ferritin dosage in our tertiary center in Lyon, France. On a dataset of 207 adult patients with 26 variables, our model showed good overall diagnostic performances with a sensitivity of 71.4% and high specificity, and positive and negative predictive values which were 100%, 100%, and 96.9%, respectively. Although generalization is difficult on a selected population, this is the first study to date to provide a machine-learning model for HLH detection. Further studies will be required to improve the machine learning model performances with a large number of HLH cases and with appropriate controls.
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