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Tantawy AA, Elsherif NHK, Elsayed SM, Ali HGA, Makkeyah SM, Elsantiel HIE, de Saint Basile G, Ragab IA. Hemophagocytic lymphohistiocytosis in Egyptian children: diagnosis, treatment challenges, and outcome. Expert Rev Hematol 2024; 17:153-163. [PMID: 38597207 DOI: 10.1080/17474086.2024.2341044] [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: 08/02/2023] [Accepted: 03/02/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Hemophagocyticlymphohistiocytosis (HLH) is a spectrum of immune activation which could be genetically determined, or secondary to an underlying illness. Our aim was to present the clinico-genetic aspects of HLH among Egyptian children and to evaluate the patterns of reactivation and outcome with illustrations of overlap manifestations. RESEARCH DESIGNAND METHODS We retrospectively collected the data of 55 patients with HLH, registered at Ain Shams University Children's Hospital,Cairo, Egypt. RESULTS Median age at diagnosis was 19 months (range 2-180), 33 patients (60%) fulfilled the diagnostic HLH criteria at presentation. Fourteen (25.45%) patients had secondary HLH, 15 (27.27%) patients had genetically documented familial HLH (11 had variants in UNC13D gene and one in PRF1 gene), 3 had Griscelli and Chediak-Higashi syndromes. Sixteen patients (29.1%) had reactivations, 8 (50%) of them had molecularly confirmed HLH. We report the death of 40 patients, the median duration from the diagnosis to death of 5 months mostly due to disease activity. CONCLUSIONS This study confirms that the nonspecific signs and symptoms of HLH are challenging. Genetic testing, though expensive and sophisticated, is integral for the diagnosis. The difficulty in finding non-related donors for stem cell transplantation and the early reactivations are the causes of the inferior outcome.
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Affiliation(s)
- Azza A Tantawy
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Nayera H K Elsherif
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Solaf M Elsayed
- Medical Genetics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba G A Ali
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Sara M Makkeyah
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Hisham I E Elsantiel
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Geneviève de Saint Basile
- Université de Paris, Imagine Institute, Paris, France
- Centre d'Etude des Déficits Immunitaires, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Iman A Ragab
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
- Department of Pediatrics, Ibn Sina National College of medical science, Jeddah, Saudi Arabia
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Yue Y, Fan S, Liu Z, Jiang F, Chen J, Qin J, Sun Y. Sequential haplo-identical conditioning transplant regimen for pediatric patients with relapsed or refractory hemophagocytic lymphohistiocytosis. Bone Marrow Transplant 2024; 59:513-517. [PMID: 38287082 DOI: 10.1038/s41409-024-02212-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/31/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) currently stands as the sole remedy for individuals afflicted with hemophagocytic lymphohistiocytosis (HLH). In this study, we retrospectively evaluated how pediatric patients with relapsed or refractory (R/R) HLH responded to our institution's cocktail conditioning regimen. The disease was diagnosed according to criteria applicable to patients with familial/genetic, relapsing, or severe/persistent HLH. All donors were HLA haplo-identical family donors. In our cohort, sixty-five patients (P-HLH), including 28 with familial/genetic HLH, 36 with secondary HLH, and 1 with an unknown cause, underwent haplo-identical family donor HSCT. The conditioning regimen consisted of intravenous administration of etoposide (VP-16), busulfan, fludarabine, rabbit anti-human thymocyte globulin (r-ATG), and cyclophosphamide (Cy). Tacrolimus and mycophenolate mofetil were used for graft-versus-host disease (GvHD) prevention. We observed that the median time for neutrophil recovery was 11 days (range, 8-24), and for platelet counts to exceed 20 × 109/L, it was 14 days (range, 7-130). There were 5 patients (7.7%) who experienced grades III to IV acute GvHD, and 6 patients (9.2%) developed extensive chronic GvHD. The estimated 3- and 5-year overall survival rates were 78.1% (95% CI, 65.8-84.6%) and 74.9% (95% CI, 61.2-84.4%), respectively. The estimated 3- and 5-year event-free survival rates were 73.5% (95% CI, 60.8-82.6%) and 70.3% (95% CI, 56.4-80.5%), respectively. Our findings demonstrate that our innovative conditioning regimen is both effective and safe, offering valuable insights for healthcare professionals evaluating the merits of existing therapies.
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Affiliation(s)
- Yan Yue
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Shifen Fan
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Zhouyang Liu
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Fan Jiang
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Jiao Chen
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Jiayue Qin
- Department of Medical Affairs, Acornmed Biotechnology Co., Ltd., Tianjin, China
| | - Yuan Sun
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China.
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3
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Kim JH, Chung JY, Bong JB. Probable secondary hemophagocytic lymphohistiocytosis manifesting as central nervous system lesions after COVID-19 vaccination: a case report. Front Neurol 2024; 15:1363072. [PMID: 38529033 PMCID: PMC10962393 DOI: 10.3389/fneur.2024.1363072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/26/2024] [Indexed: 03/27/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare systemic inflammatory disease commonly characterized by histiocyte infiltration in multiple organs, such as the liver, spleen, lymph nodes, bone marrow, and central nervous system. The clinical features of HLH include fever, splenomegaly, cytopenia, hypertriglyceridemia, hypofibrinogenemia, and elevated blood ferritin levels. HLH is categorized as either primary or secondary. Coronavirus disease 2019 (COVID-19) vaccines may occasionally trigger secondary HLH, which is related to hyperinflammatory syndrome. Case presentation A 58-year-old woman, previously diagnosed with Graves' disease, presented with cognitive decline 2 weeks after receiving the first dose of the ChAdOx1 nCoV-19 vaccine. Brain MRI revealed a hyperintense lesion on T2-weighted and fluid-attenuated inversion recovery images in the bilateral subcortical white matter and right periventricular area. Vaccination-associated acute disseminated encephalomyelitis was suspected and methylprednisolone and intravenous immunoglobulin (IVIg) were administered. From the 5th day of IVIg administration, the patient developed fever and pancytopenia. In the findings of bone marrow biopsy, hemophagocytosis was not observed; however, six of the eight diagnostic criteria for HLH-2004 were met, raising the possibility of HLH. Although there was no definitive method to confirm causality, considering the temporal sequence, suspicion arose regarding vaccine-induced HLH. Splenectomy was considered for therapeutic and diagnostic purposes; however, the patient died on the 28th day of hospitalization owing to multiple organ failure. Conclusion To date, 23 cases of COVID-19 vaccine-related HLH have been reported. Additionally, HLH in COVID-19 patients has been reported in various case reports. To the best of our knowledge, this is the first reported case of central nervous system involvement in HLH related to any type of COVID-19 vaccine. This case suggests that even when there are no systemic symptoms after COVID-19 vaccination, HLH should be considered as a differential diagnosis if brain lesions are suggestive of CNS demyelinating disease.
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Affiliation(s)
| | | | - Jeong Bin Bong
- Department of Neurology, Chosun University College of Medicine, Gwangju, Republic of Korea
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Ge J, Zhang Q, Ma H, Wang D, Zhao Y, Zhu T, Wang W, Zhou C, Wei A, Lian H, Qin M, Yang J, Li Z, Wang T, Zhang R. Ruxolitinib-based regimen in children with primary hemophagocytic lymphohistiocytosis. Haematologica 2024; 109:458-465. [PMID: 37470145 PMCID: PMC10828753 DOI: 10.3324/haematol.2023.283478] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023] Open
Abstract
Primary hemophagocytic lymphohistiocytosis (pHLH) is a rare immune disorder and hematopoietic stem cell transplan- tation (HSCT) is the only potentially curative treatment. Given the high pre-HSCT mortality of pHLH patients reported in the HLH-2004 study (17%), more regimens to effectively control the disease and form a bridge with HSCT are needed. We conducted a retrospective study of pHLH children treated by ruxolitinib (RUX)-based regimen. Generally, patients received RUX until HSCT or unacceptable toxic side-effect. Methylprednisolone and etoposide were added sequentially when the disease was suboptimally controlled. The primary end point was 1-year overall survival. Twenty-one pHLH patients (12 previously treated and 9 previously untreated) were included with a median follow-up of 1.4 years. At last follow-up, 17 (81.0%) patients were alive with a 1-year overall survival of 90.5% (95% confidence interval: 84.1-96.9). Within the first 8 weeks, all patients had an objective response, of which 19 (90.5%) achieved complete response (CR) and two (9.5%) achieved partial response (PR) as a best response. Seventeen (81.0%) patients received HSCT, of which 13 (76.5%) had CR, three (17.6%) had PR and one (5.9%) had disease reactivation at the time of HSCT. Fifteen (88.2) patients were alive post- HSCT. Notably, eight (38.1%) patients received zero doses of etoposide, suggesting the potential of RUX-based regimen to reduce chemotherapy intensity. Patients tolerated RUX-based regimen well and the most frequently observed adverse events were hematologic adverse events. Overall, RUX-based regimen was effective and safe and could be used as a bridge to HSCT for pHLH children.
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Affiliation(s)
- Jian Ge
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Qing Zhang
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Honghao Ma
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Dong Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Yunze Zhao
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Ting Zhu
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Wenqian Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Chenxin Zhou
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Ang Wei
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Hongyun Lian
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Maoquan Qin
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing
| | - Jun Yang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing
| | - Zhigang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Tianyou Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Rui Zhang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing.
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5
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Zhao C, Zhang Q, Zhang R, Lian H, Ma H, Zhao X, Li Z. Genetic and clinical characteristics of primary hemophagocytic lymphohistiocytosis in children. Ann Hematol 2024; 103:17-28. [PMID: 37851074 DOI: 10.1007/s00277-023-05499-6] [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: 07/14/2023] [Accepted: 10/07/2023] [Indexed: 10/19/2023]
Abstract
To analyze the genetic variation and prognosis of primary hemophagocytic lymphohistiocytosis (pHLH) in children and the clinical features of isolated central nervous system HLH (CNS-HLH). We retrospectively analyzed the clinical and genetic data of 480 HLH children admitted to our hospital from September 2017 to September 2022. There were 66 patients (13.75%) with pHLH, and the median age was 3.21 years (0.17-12.92 years). Variants in UNC13D (22/66, 33.33%), PRF1 (20/66, 30.30%) and XIAP (11/66, 16.67%) were the most common. More CNS involvement was observed in pHLH patients than in secondary hemophagocytic lymphohistiocytosis (sHLH) patients (50% vs. 25.3%, P = 0.001). Eight pHLH patients had isolated CNS-HLH at onset, which progressed to systemic HLH within 10-30 days to several years. Among them, five patients who underwent hematopoietic stem cell transplantation (HSCT) survived without CNS sequelae, and the three patients who did not undergo HSCT died of disease progression or recurrence. Determination of natural killer (NK) cell cytotoxicity and CD107a levels had low sensitivity and specificity in the diagnosis of pHLH, especially in patients with PRF1 and XIAP mutations. The 3-year overall survival (OS) was significantly lower in pHLH patients than in sHLH patients (74.5% ± 14.7% vs. 89.2% ± 3.53%, P = 0.021) and in patients with CNS involvement than in those without (53.8% ± 26.07% vs. 94.4% ± 10.58%, P = 0.012). There was a significant difference in OS among pHLH patients with different gene variants (P = 0.032); patients with PRF1 variants had poor 3-year OS, and patients with XIAP variants had good 3-year OS (50% ± 28.22% and 100%, respectively). pHLH patients with distinct variants have different prognoses. Isolated CNS-HLH patients are easily misdiagnosed, and HSCT may be beneficial for these patients. Determination of NK cell cytotoxicity and CD107a levels cannot precisely distinguish pHLH from sHLH.
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Affiliation(s)
- Chenzi Zhao
- Laboratory of Hematologic Diseases, Hematology Center, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Qing Zhang
- Laboratory of Hematologic Diseases, Hematology Center, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Rui Zhang
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Hongyun Lian
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Honghao Ma
- Beijing Key Laboratory of Pediatric Hematology Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Xiaoxi Zhao
- Laboratory of Hematologic Diseases, Hematology Center, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Zhigang Li
- Laboratory of Hematologic Diseases, Hematology Center, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nanlishi Road, Xicheng District, Beijing, 100045, China.
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6
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Cox MF, Mackenzie S, Low R, Brown M, Sanchez E, Carr A, Carpenter B, Bishton M, Duncombe A, Akpabio A, Kulasekararaj A, Sin FE, Jones A, Kavirayani A, Sen ES, Quick V, Dulay GS, Clark S, Bauchmuller K, Tattersall RS, Manson JJ. Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline. THE LANCET. RHEUMATOLOGY 2024; 6:e51-e62. [PMID: 38258680 DOI: 10.1016/s2665-9913(23)00273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 01/24/2024]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by persistently activated cytotoxic lymphocytes and macrophages, which, if untreated, leads to multiorgan dysfunction and death. HLH should be considered in any acutely unwell patient not responding to treatment as expected, with prompt assessment to look for what we term the three Fs-fever, falling blood counts, and raised ferritin. Worldwide, awareness of HLH and access to expert management remain inequitable. Terminology is not standardised, classification criteria are validated in specific patient groups only, and some guidelines rely on specialised and somewhat inaccessible tests. The consensus guideline described in this Health Policy was produced by a self-nominated working group from the UK network Hyperinflammation and HLH Across Speciality Collaboration (HiHASC), a multidisciplinary group of clinicians experienced in managing people with HLH. Combining literature review and experience gained from looking after patients with HLH, it provides a practical, structured approach for all health-care teams managing adult (>16 years) patients with possible HLH. The focus is on early recognition and diagnosis of HLH and parallel identification of the underlying cause. To ensure wide applicability, the use of inexpensive, readily available tests is prioritised, but the role of specialist investigations and their interpretation is also addressed.
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Affiliation(s)
- Miriam F Cox
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Strachan Mackenzie
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ryan Low
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael Brown
- Division of Infection, University College London Hospitals NHS Foundation Trust, London, UK
| | - Emilie Sanchez
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling Carr
- Centre for Neuromuscular Diseases, National hospital of Neurology and Neurosurgery, London, UK
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Bishton
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - Akpabio Akpabio
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - Fang En Sin
- Department of Rheumatology, North Bristol NHS Trust, UK
| | - Alexis Jones
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Akhila Kavirayani
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vanessa Quick
- Department of Rheumatology, Bedfordshire Hospitals NHS Trust, Luton, UK
| | - Gurdeep S Dulay
- Department of Rheumatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Clark
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.
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Sivaramalingam G, VK A, Raghavan B, Govindaraj J. Imaging Spectrum of Neurological Manifestations of Hemophagocytic Lymphohistiocytosis in Pediatrics: A Case Series. Indian J Radiol Imaging 2023; 33:548-554. [PMID: 37811180 PMCID: PMC10556316 DOI: 10.1055/s-0043-1772495] [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] [Indexed: 10/10/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition, which can result either from a primary genetic abnormality affecting children or secondary to various conditions like malignancy or infection predominantly in adults. HLH is associated with immune dysregulation, resulting in an uncontrolled overproduction and infiltration of lymphocytes and histiocytes. The infiltration predominantly involves liver, spleen, lymph nodes, and central nervous system. Neuroimaging features on magnetic resonance imaging are highly nonspecific and variable. The most typical findings include periventricular white matter hyperintensities and diffuse atrophy. Ring or nodular enhancing or nonenhancing focal parenchymal lesions may be seen. Here, we present three pediatric cases of primary HLH with a wide spectrum of imaging findings involving cerebral and cerebellar cortex, white matter, deep gray matter, and brain stem. The findings in these patients range from small nonenhancing hemorrhagic lesions and enhancing small lesions to ill-defined mass with mass effect and midline shift. Lesions in deep gray matter including thalamus, basal ganglia, and also brain stem in HLH are rarely described in literature. Early diagnosis of HLH and timely management can improve the course of the disease.
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Affiliation(s)
| | - Afiya VK
- Department of Radiology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - Bagyam Raghavan
- Department of Radiology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - Jayaraj Govindaraj
- Department of Radiology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
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8
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS). Arthritis Rheumatol 2023; 75:1714-1732. [PMID: 37486733 PMCID: PMC11040593 DOI: 10.1002/art.42636] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, NIH, Bethesda, Maryland
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, and Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hines
- Pediatric Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University and Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children’s Hospital, Houston
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward M. Behrens
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Randy Q. Cron
- Pediatric Rheumatology, University of Alabama at Birmingham
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California
| | - Alexei A. Grom
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Lauren A. Henderson
- Pediatric Immunology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annacarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B. Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Kim E. Nichols
- Division of Cancer Predisposition Department of Oncology, St. Jude Children’s Research Hospital Department of Oncology, Memphis, Tennessee
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | | | - Rebecca A. Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Scott W. Canna
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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9
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Charpentier H, Roux CJ, Leroux P, Briand C, Levy R, Dangouloff-Ros V, Desguerre I, Neven B, Moshous D, Boddaert N. Spectrum of neuroradiological manifestations in primary hemophagocytic lymphohistiocytosis: a comparative study of EBV-induced versus non-EBV-induced forms in 75 genetically confirmed pediatric cases. Eur Radiol 2023; 33:7149-7159. [PMID: 37171488 DOI: 10.1007/s00330-023-09649-2] [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: 07/03/2022] [Revised: 12/23/2022] [Accepted: 02/09/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening condition affecting young children. It is potentially triggered by Epstein-Barr virus (EBV). This study describes the neuroradiological features observed in 75 children with genetically confirmed primary HLH, comparing EBV-induced with non-EBV-induced HLH forms. METHODS Brain MRIs between 2007 and 2021 from 75 children with HLH according to the 2004 Histiocyte Society criteria and with a confirmed HLH-related mutation, were retrospectively reviewed by two pediatric neuroradiologists blinded to EBV status and to mutation status. At diagnosis, 17 children with EBV viremia above a threshold of 1000 copies/mL were included in the EBV-induced HLH group. The remaining 58 patients were included in the non-EBV-induced HLH group. RESULTS Of the 75 children initially included, 21 had abnormal MRI (21/75 (28%); 9/17 in the EBV-induced HLH group and 12/58 in the non-EBV-induced HLH group). All patients with abnormal MRI had neurological symptoms. Abnormal MRIs showed white matter lesions; the posterior fossa was affected in all but one case. There was no significant difference between groups regarding the localization or morphology of white matter lesions. The striatum was more frequently affected in the EBV-induced HLH group (8/9 (89%) versus 1/12 (8%), p = 0.00037). All lesions, whether in the white matter or in the basal ganglia, presented increased ADC values on diffusion weighted imaging (DWI). CONCLUSION In this study of 75 children with genetically confirmed HLH, only children with neurological signs had abnormal brain MRI. Bilateral striatum involvement suggested an EBV-induced form of HLH. KEY POINTS • In children with genetically proven HLH, only those with neurological signs did have brain abnormalities at MRI. • All patients with abnormal brain MRI had multiple white matter lesions with increased ADC values, including in the posterior fossa in almost all cases. • Basal ganglia and in particular the striatum were bilaterally and symmetrically affected in almost all EBV-induced HLH patients, in contrast to the non-EBV-induced HLH patients.
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Affiliation(s)
- Hélène Charpentier
- Department of Radiology, University Hospital Besançon, 25000, Besançon, France.
- University Hospital Besançon, 3 Boulevard Fleming, 25030, Besançon, France.
| | - Charles-Joris Roux
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, 75015, Paris, France
| | - Pauline Leroux
- Department of Pediatrics, Sud Francilien Hospital, 91100, Corbeil-Essonnes, France
| | - Coralie Briand
- Department of Pediatrics, Jean-Verdier Hospital, 93140, Bondy, France
| | - Raphaël Levy
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, 75015, Paris, France
| | - Volodia Dangouloff-Ros
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, 75015, Paris, France
| | - Isabelle Desguerre
- Department of Neurology and Metabolism, Necker-Enfants Malades Hospital, 75015, Paris, France
| | - Bénédicte Neven
- Department of Pediatric Immunology, Hematology, and Rheumatology, Necker-Enfants Malades Hospital, 75015, Paris, France
| | - Despina Moshous
- Department of Pediatric Immunology, Hematology, and Rheumatology, Necker-Enfants Malades Hospital, 75015, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker-Enfants Malades Hospital, 75015, Paris, France
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10
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). Ann Rheum Dis 2023; 82:1271-1285. [PMID: 37487610 PMCID: PMC11017727 DOI: 10.1136/ard-2023-224123] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa Hines
- Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children's Hospital, Houston, Texas, USA
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California, USA
| | - Alexei A Grom
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren A Henderson
- Pediatric Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Annacarin Horne
- Department of Women's and Children's Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Kim E Nichols
- Division of Cancer Predisposition Department of Oncology, St Jude Children's Research Hospital Department of Oncology, Memphis, Tennessee, USA
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Rebecca A Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Scott W Canna
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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11
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Zhou KG, Gong DH, Peng D, Wang ZQ, Huang W. Clinical profile, etiology, and outcome of hemophagocytic lymphohistiocytosis associated with histiocytic necrotizing lymphadenitis. World J Pediatr 2023; 19:406-410. [PMID: 36595187 PMCID: PMC10060272 DOI: 10.1007/s12519-022-00660-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Kuang-Guo Zhou
- Department of Hematology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Jiefang Road 1095#, Wuhan, 430030, China
| | - Duan-Hao Gong
- Department of Hematology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Jiefang Road 1095#, Wuhan, 430030, China
| | - Dan Peng
- Department of Nuclear Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-Qiong Wang
- Department of Hematology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Jiefang Road 1095#, Wuhan, 430030, China
| | - Wei Huang
- Department of Hematology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Jiefang Road 1095#, Wuhan, 430030, China.
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12
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Santos IO, Neto RP, Bom APKP. Hemophagocytic lymphohistiocytosis: a case series analysis in a pediatric hospital. Hematol Transfus Cell Ther 2023; 45:32-37. [PMID: 34183298 PMCID: PMC9938491 DOI: 10.1016/j.htct.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/02/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a rare clinical laboratory condition with high mortality rates, resulting from ineffective overactivation of the immune system. Data in the Brazilian literature is scarce, contributing to the challenge in standardizing conducts and performing an early diagnosis of HLH. OBJECTIVE To describe the clinical, laboratory, and evolutionary findings on HLH patients treated at a pediatric hospital. METHODS This is an observational, cross-sectional and retrospective study on children diagnosed with HLH, hospitalized between 2009 and 2019. The diagnostic criteria were those described in the Histiocyte Society protocol. The authors evaluated HLH patient laboratory tests, myelograms and bone marrow biopsies, clinical characteristics and therapy. RESULTS Twenty-three patients were included, 52.2% of whom were males. The age at diagnosis ranged from one to one hundred and eighty months. Four cases were classified as Primary HLH and nineteen, as Secondary HLH. The main triggers were infections and rheumatological diseases. All children had bicytopenia, and 95.4% had hyperferritinemia. Nineteen patients had liver dysfunction, sixteen had neurological disorders and fourteen had kidney injury. Pulmonary involvement was seen in 61.9%, acting as a worse prognosis for death (p = 0.01). Nine patients underwent the immuno-chemotherapy protocol proposed in the HLH 2004. The time to confirm the diagnosis varied from five to eighty days. The lethality found was 56.3%. CONCLUSIONS The present study is the most extensive retrospective exclusively pediatric study published in Brazil to date. Despite the limitations, it was possible to demonstrate the importance of discussing HLH as a pediatric emergency.
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Affiliation(s)
| | | | - Ana Paula Kuczynski Pedro Bom
- Hospital Pequeno Prínicpe, Curitiba, PR, Brazil,Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR, Brazil
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13
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Tlais D, Fetzko S, Gulati N, Tran HBD, Risen S, Lai YC. A Toddler With New Seizures, Progressive White Matter Lesions, and Multifocal Microhemorrhages. Pediatrics 2022; 150:189899. [PMID: 36325804 PMCID: PMC10026691 DOI: 10.1542/peds.2022-057652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
Abstract
A 16-month-old, previously healthy male is hospitalized for new onset seizures. Initial investigation is significant for enterovirus/rhinovirus respiratory infection, abnormal T2 signal predominantly in the white matter and scattered microhemorrhages on brain MRI, transaminitis, and thrombocytopenia. His symptoms initially improve on steroid therapy and he is discharged from the hospital. During the ensuing month with the tapering of the steroids, he develops new motor deficits for which he is rehospitalized. His laboratory investigation on readmission is unremarkable. However, there is significant progression of white matter lesions and microhemorrhages on repeat MRI. While in the hospital, he becomes febrile and has seizure recurrence and worsening neurologic symptoms, including cerebral salt wasting and encephalopathy. Subsequent neuroimaging demonstrates cerebral edema and diffuse brain injury. A high index of suspicion for a rare condition ultimately leads us to perform the specialized testing that confirms the diagnosis. We will discuss the diagnostic challenges that arise from an atypical presentation of an uncommon condition, and from the disease progression that is modified by previous interventions.
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Affiliation(s)
| | | | | | - Huy Brandon D Tran
- Department of Radiology, Division of Pediatric Neuroradiology, Baylor College of Medicine, Houston, Texas
| | | | - Yi-Chen Lai
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine
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14
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Ou W, Ma H, Wei A, Zhao Y, Zhang L, Lian H, Zhang Q, Chen S, Wang D, Li Z, Zhang R, Wang T. Clinical significance of cerebrospinal fluid soluble CD25 in pediatric hemophagocytic lymphohistiocytosis with central nervous system involvement. Pediatr Blood Cancer 2022; 69:e29712. [PMID: 35441804 DOI: 10.1002/pbc.29712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/07/2022] [Accepted: 03/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To analyze the clinical significance of soluble CD25 (sCD25) levels in cerebrospinal fluid (CSF) in pediatric hemophagocytic lymphohistiocytosis (HLH) with central nervous system (CNS) involvement. METHODS All patients diagnosed with HLH admitted to Beijing Children's Hospital, Capital Medical University between January 1, 2017 and October 31, 2021 who received a measurement of their HLH-related parameters and CSF sCD25 levels at admission were enrolled in this study. RESULTS CSF sCD25 levels in patients with primary HLH were higher than those in patients with Epstein-Barr virus infection-associated HLH, and the median level was 444 pg/ml. The difference in CSF sCD25 levels between the non-CNS group and the CNS group was statistically significant (591 [259-33,643] pg/ml vs. 123 (36-437) pg/ml, p < .001). The best cutoff value of CSF sCD25 was 273.5 pg/ml (AUC = 0.987, 95% CI: 0.972-1.000), with sensitivity, specificity, positive predictive values, and negative predictive values of 96.4%, 92.8%, 81.8%, and 98.7%, respectively. CSF sCD25 in the severe CNS involvement group was significantly higher than that in the nonsevere CNS involvement group (p = .014). The 3-year overall survival (OS) of patients with high CSF sCD25 levels was lower than that of patients with low CSF sCD25 levels(71.6% ± 8.1% vs. 93.3% ± 2.9%, hazard ratio [HR] = 3.637, p = .003). CONCLUSION Increased CSF sCD25 levels in active disease can predict CNS-HLH. Primary HLH has a higher CSF sCD25 level than Epstein-Barr virus infection-associated HLH. Patients who are diagnosed with CNS-HLH with CSF sCD25 levels higher than 273.5 pg/ml are more likely to develop severe CNS involvement, suggesting a poor prognosis.
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Affiliation(s)
- Wenxin Ou
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Honghao Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ang Wei
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yunze Zhao
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Liping Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hongyun Lian
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qing Zhang
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Sitong Chen
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Dong Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhigang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Rui Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Tianyou Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Disease in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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15
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Aydın K, Kılıç B, Topçu Y, Telhan L, Dolu MH, Kartal A. Brain Magnetic Resonance Imaging Findings of Pediatric Hemophagocytic Lymphohistiocytosis Could Be Diagnostic and Life-Saving. Pediatr Neurol 2022; 133:40-47. [PMID: 35753148 DOI: 10.1016/j.pediatrneurol.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/09/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal disease and may also present with central nervous system findings at the beginning without specific diagnostic criteria. Brain magnetic resonance imaging (MRI) findings are diverse and can also be diagnostic. We aimed to emphasize the importance of brain MRI findings in the early diagnosis of this fatal disease. METHODS MRI findings, clinical presentations, treatment response, and prognosis of seven patients with HLH were described. RESULTS There were seven pediatric patients who were initially diagnosed with HLH with neurological findings without systemic signs of HLH: four as primary, two as secondary, and one as possible primary HLH. All patients had contrast-enhancing diffuse cerebellar and brainstem lesions; patchy periventricular and callosal cerebral lesions were observed. Thalamus involvement was found in three (42.8%), corpus callosum involvement in six (85.7%), and cervical spinal involvement in one (14.2%). Patients were followed up with these MRI findings, with prediagnoses of toxic, metabolic, infectious, vascular, and demyelinating diseases. Not all patients met the HLH diagnostic criteria due to incomplete systemic/laboratory findings; therefore, only two were immediately directed for hematopoietic stem cell therapy. Four died shortly after admission, one patient could not be followed up after HLH treatment, and two patients who fulfilled the HLH diagnostic criteria underwent hematopoietic stem cell transplantation and survived. CONCLUSIONS Brain MRI findings, especially in the presence of neurological findings, allow for early diagnosis, which can be life-saving. These common features in brain MRI findings should be evaluated with this suspicion and included in HLH diagnostic criteria.
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Affiliation(s)
- Kürşad Aydın
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Betül Kılıç
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey.
| | - Yasemin Topçu
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Leyla Telhan
- Department of Pediatric Intensive Care Unit, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Merve Hilal Dolu
- Department of Pediatric Neurology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Ayşe Kartal
- Department of Pediatric Neurology, Selçuk University Faculty of Medicine, Konya, Turkey
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16
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Shi FE, Chen MF, Li YJ, Dong GY, Zhu JH. Campylobacter jejuni-Associated Hemophagocytic Lymphohistiocytosis and Guillain-Barre Syndrome: A Case Report. Front Med (Lausanne) 2022; 9:895923. [PMID: 35872780 PMCID: PMC9302883 DOI: 10.3389/fmed.2022.895923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/20/2022] [Indexed: 01/23/2023] Open
Abstract
Campylobacter jejuni (C. jejuni), a Gram-negative bacterium, belongs to microaerobic bacteria. We reported a 21-year-old male patient diagnosed with hemophagocytic lymphohistiocytosis (HLH) due to C. jejuni infection, who presented with multiple clinical manifestations of peripheral nerve injury, such as ophthalmoplegia, facial paralysis, and urinary retention during the treatment. Electromyography showed neurogenic injury and the final diagnosis was Guillain-Barre Syndrome (GBS). After treatment of dexamethasone combined with immunoglobulin, the patient was discharged from the hospital with partial recovery of neurological symptoms.
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Affiliation(s)
- Fang-e Shi
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Mei-fang Chen
- Department of Infectious Diseases, Peking University People's Hospital, Beijing, China
| | - Yong-jie Li
- Department of Neurology, Peking University People's Hospital, Beijing, China
| | - Gui-ying Dong
- Department of Emergency, Peking University People's Hospital, Beijing, China
- *Correspondence: Gui-ying Dong
| | - Ji-hong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
- Ji-hong Zhu
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17
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Cooray S, Sabanathan S, Hacohen Y, Worth A, Eleftheriou D, Hemingway C. Treatment Strategies for Central Nervous System Effects in Primary and Secondary Haemophagocytic Lymphohistiocytosis in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose of Review
This review presents an appraisal of current therapeutic options for the treatment of central nervous system haemophagocytic lymphohistiocytosis (CNS-HLH) in the context of systemic disease, as well as when CNS features occur in isolation. We present the reader with a diagnostic approach to CNS-HLH and commonly used treatment protocols. We discuss and evaluate newer treatments on the horizon.
Recent Findings
Mortality is high in patients who do not undergo HSCT, and while larger studies are required to establish benefit in many treatments, a number of new treatments are currently being evaluated. Alemtuzumab is being used as a first-line treatment for CNS-HLH in a phase I/II multicentre prospective clinical trial as an alternative to traditional HLH-1994 and 2004 protocols. It has also been used successfully as a second-line agent for the treatment of isolated CNS-HLH that is refractory to standard treatment. Ruxolitinib and emapalumab are new immunotherapies that block the Janus kinase—Signal Transducer and Activator of Transcription (JAK-STAT) pathway that have shown efficacy in refractory HLH, including for CNS-HLH disease.
Summary
Treatment of CNS-HLH often requires HLH-94 or 2004 protocols followed by haematopoietic stem cell transplantation (HSCT) to maintain remission, although relapse can occur, particularly with reduced intensity conditioning if donor chimerism falls. CNS features have been shown to improve or stabilise following HSCT in CNS-HLH in the context of systemic disease and in isolated CNS-HLH. Encouraging reports of early cohort studies suggest alemtuzumab and the Janus kinase (JAK) inhibitor ruxolitinib offer potential salvage therapy for relapsed and refractory CNS-HLH. Newer immunotherapies such as tocilizumab and natalizumab have been shown to be beneficial in sporadic cases. CNS-HLH due to primary gene defects may be amenable to gene therapy in the future.
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Han HJ, Parks AL, Shah MP, Hsu G, Santhosh L. An Elusive Seizure. Neurohospitalist 2022; 12:188-194. [PMID: 34950412 PMCID: PMC8689556 DOI: 10.1177/19418744211018096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We present a case of a healthy 62-year-old woman who developed recurrent seizures preceded by subacute cognitive slowing, ataxia, night sweats, and weight loss. She was found to have cytopenias, multifocal T2/FLAIR hyperintensities on magnetic resonance imaging (MRI), and magnetic susceptibility artifact lesions on susceptibility weighted imaging (SWI). Her symptoms, imaging and laboratory abnormalities all improved with high-doses of steroids and intravenous immunoglobulin (IVIG). But recurred several weeks after completing treatment. Despite extensive work-up, she required multiple hospitalizations and repeat diagnostic studies to arrive at a diagnosis. With an expert discussant in hematology and oncology, we review the differential diagnosis and stepwise approach of unexplained neuro-inflammatory syndromes with cytopenias and systemic symptoms. Our case highlights how time, empiric treatment response, and repeated diagnostic studies refine differential diagnoses and subsequent evaluation. After revealing the diagnosis, we discuss the heterogenous clinical manifestations of this disease process.
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Affiliation(s)
- Harry J. Han
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Anna L. Parks
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Maulik P. Shah
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Gerald Hsu
- Department of Medicine, University of California, San Francisco, CA, USA,Division of Hematology/Oncology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA. Han is now with Harvard Interprofessional Palliative Care Fellowship, Massachusetts General Hospital and the Dana Farber Cancer Institute, Boston, MA, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California, San Francisco, CA, USA,Lekshmi Santhosh, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco CA 94143, USA.
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Harnchoowong S, Soponkanaporn S, Vilaiyuk S, Lerkvaleekul B, Pakakasama S. Central nervous system involvement and thrombocytopenia as predictors of mortality in children with hemophagocytic lymphohistiocytosis. Front Pediatr 2022; 10:941318. [PMID: 36147804 PMCID: PMC9485874 DOI: 10.3389/fped.2022.941318] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/18/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening condition. This study aimed to evaluate treatment outcomes and identify prognostic-related factors in Thai children with HLH. MATERIALS AND METHODS We retrospectively reviewed the medical records of 76 pediatric patients with HLH who were treated at Ramathibodi Hospital between January 2004 and December 2019. Treatment outcomes were defined as early mortality (death within 30 days after diagnosis) and early treatment response (resolution of all clinical features and normalization of at least one HLH-related laboratory parameter within 4 weeks). RESULTS The overall mortality rate was 38% (29/76), with an early mortality rate of 45% (13/29). Malignancy-associated HLH had the highest mortality rate (88%), followed by primary HLH (56%). The predictors of early mortality were central nervous system (CNS) involvement [OR 13 (95%CI 2-83), p = 0.007] and platelet counts <44 × 106/mm3 [OR 8 (95%CI 1.3-49), p = 0.024]. The predictors of early treatment response were no CNS involvement [OR 6.6 (95%CI 1.5-28.8), p = 0.011], platelet counts more than 44 × 106/mm3 [OR 8 (95%CI 2.1-30.9), p = 0.003], and total bilirubin levels <1.8 mg/dL [OR 4 (95%CI 1.1-14.8), p = 0.036]. In the mixed-model analysis, platelet counts in non-survivors increased significantly less than those in survivors, with a mean difference in platelet changes between the two groups of 94.6 × 106/mm3 (p = 0.003). CONCLUSION The independent predictors of early mortality in children with HLH were CNS involvement and low baseline platelet counts. A slow rate of platelet increases during the first week after diagnosis was also associated with mortality.
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Affiliation(s)
- Saralee Harnchoowong
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirisucha Soponkanaporn
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Butsabong Lerkvaleekul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Samart Pakakasama
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Zhang L, Dai L, Li D. Risk factors of early death in pediatric hemophagocytic lymphohistocytosis: Retrospective cohort study. Front Pediatr 2022; 10:1031432. [PMID: 36340709 PMCID: PMC9634417 DOI: 10.3389/fped.2022.1031432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome in which early mortality remains high in patients with HLH. METHODS We retrospectively collected the medical records of all pediatric patients diagnosed with HLH at the West China Second Hospital of Sichuan University between January 2014 and December 2020. Collect demographic, laboratory, clinical, genetic profiles, treatment information and perform statistical analysis from records. Risk factors for death 30 days after admission were evaluated using a multivariable logistic regression model. RESULTS A total of 110 pediatric HLH patients were enrolled. The median age of patients was 44 months (IQR 23-100.5) and 62 (56.4%) in males. The 30-day mortality rate for admission to this cohort was 34 (30.9%). Multivariate logistic regression analysis showed that heart failure (OR = 13.389, 95% CI, 1.671-107.256, p = 0.015) and hypoproteinemia (OR = 4.841, 95% CI, 1.282-18.288, p = 0.020) were associated with increased early mortality in children with HLH. CONCLUSIONS These identified risk factors may help clinicians stratify patients with HLH and develop targeted treatment strategies. More research is needed to explore the best treatment strategies for patients with HLH to reduce early mortality in patients with HLH.
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Affiliation(s)
- Lijun Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Lei Dai
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Deyuan Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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21
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Detection and Prediction of Macrophage Activation Syndrome in Still's Disease. J Clin Med 2021; 11:jcm11010206. [PMID: 35011947 PMCID: PMC8745834 DOI: 10.3390/jcm11010206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/21/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
Distinguishing between macrophage activation syndrome (MAS) and a simple flare of Still’s disease (SD) may be challenging. We sought to clarify the clinical features and outcome of MAS in SD and to explore predictive factors of MAS development. Demographic and clinical data, treatments, and outcomes were recorded in a cohort of 206 SD patients. SD patients with and without MAS were compared. To explore predictive factors for the development of MAS, patients were compared at the time of SD diagnosis. Twenty (9.7%) patients experienced MAS, which was inaugural in 12 cases. Patients with MAS were more likely to have hepatomegaly (OR, 3.71; 95% CI, 1.14–11.2; p = 0.03) and neurological symptoms (OR, 4.43; 95% CI, 1.08–15.3; p = 0.04) than patients without MAS. Cytopenias, abnormal liver tests, and coagulation disorders were significantly more frequent in patients with MAS; lactate dehydrogenase and serum ferritin levels were significantly higher. An optimized threshold of 3500 μg/L for serum ferritin yielded a sensitivity (Se) of 85% and a negative predictive value (NPV) of 97% for identifying patients with/without MAS. Survival analysis showed that a high ferritin level at the time of SD diagnosis was predictive of MAS development (p < 0.001). Specific factors, including neurological symptoms, cytopenias, elevated LDH, and coagulopathy, may contribute to the early detection of MAS. Extreme hyperferritinemia at the onset of SD is a prognostic factor for the development of MAS.
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22
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Malik P, Antonini L, Mannam P, Aboobacker FN, Merve A, Gilmour K, Rao K, Kumar S, Mani SE, Eleftheriou D, Rao A, Hemingway C, Sudhakar SV, Bartram J, Mankad K. MRI Patterns in Pediatric CNS Hemophagocytic Lymphohistiocytosis. AJNR Am J Neuroradiol 2021; 42:2077-2085. [PMID: 34620587 DOI: 10.3174/ajnr.a7292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/19/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Neuroimaging has an important role in detecting CNS involvement in children with systemic or CNS isolated hemophagocytic lymphohistiocytosis. We characterized a cohort of pediatric patients with CNS hemophagocytic lymphohistiocytosis focusing on neuroradiologic features and assessed whether distinct MR imaging patterns and genotype correlations can be recognized. MATERIALS AND METHODS We retrospectively enrolled consecutive pediatric patients diagnosed with hemophagocytic lymphohistiocytosis with CNS involvement treated at 2 pediatric neurology centers between 2010 and 2018. Clinical and MR imaging data were analyzed. RESULTS Fifty-seven children (40 primary, 70%) with a median age of 36 months (interquartile range, 5.5-80.8 months) were included. One hundred twenty-three MR imaging studies were assessed, and 2 broad imaging patterns were identified. Pattern 1 (significant parenchymal disease, 32/57, 56%) was seen in older children (P = .004) with worse clinical profiles. It had 3 onset subpatterns: multifocal white matter lesions (21/32, 66%), brainstem predominant disease (5, 15%), and cerebellitis (6, 19%). All patients with the brainstem pattern failed to meet the radiologic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. An attenuated imaging phenotype (pattern 2) was seen in 25 patients (44%, 30 studies) and was associated with younger age. CONCLUSIONS Distinct MR imaging patterns correlating with clinical phenotypes and possible genetic underpinnings were recognized in this cohort of pediatric CNS hemophagocytic lymphohistiocytosis. Disruptive mutations and missense mutations with absent protein expression correlate with a younger onset age. Children with brainstem and cerebellitis patterns and a negative etiologic work-up require directed assessment for CNS hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- P Malik
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | - L Antonini
- Department of Paediatric Hemato-Oncology (L.A.), G. Salesi Hospital, Ancona, Italy
| | - P Mannam
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | | | - A Merve
- Department of Histopathology (A.M.)
| | | | - K Rao
- Bone Marrow Transplant Unit (K.R.)
| | - S Kumar
- Child Heath (S.K.), Christian Medical College, Vellore, India
| | - S E Mani
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | - D Eleftheriou
- Paediatric Rheumatology (D.E.), Great Ormond Street Hospital for Children and University College, London, UK
| | - A Rao
- Department of Pediatric Hematology (A.R., J.B.)
| | | | | | - J Bartram
- Department of Pediatric Hematology (A.R., J.B.)
| | - K Mankad
- Pediatric Neuroradiology Unit (S.V.S., K.M.)
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Wang W, Yang X, Yang J. Multiple-Organ Involvement in Familial Hemophagocytic Lymphohistiocytosis Type 2 Shown on FDG PET/CT. Clin Nucl Med 2021; 46:935-937. [PMID: 34034321 DOI: 10.1097/rlu.0000000000003724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT FDG PET/CT in an 18-year-old man with known familial hemophagocytic lymphohistiocytosis (HLH) type 2 demonstrated abnormally in the brain, liver, and lymph nodes. Pathology showed no sign of lymphoproliferative disease. The patient underwent the chemotherapy of HLH. Six months after chemotherapy, a follow-up FDG PET/CT did not show any abnormal 18F-FDG activity, suggesting a complete response. The present case shows FDG PET/CT might not only be useful in staging the familial HLH but also able to evaluate the therapy response.
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Affiliation(s)
- Wei Wang
- From the Department of Nuclear Medicine, Beijing Friendship Hospital of Capital Medical University, Xi Cheng District, Beijing, China
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24
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Consensus-Based Guidelines for the Recognition, Diagnosis, and Management of Hemophagocytic Lymphohistiocytosis in Critically Ill Children and Adults. Crit Care Med 2021; 50:860-872. [PMID: 34605776 DOI: 10.1097/ccm.0000000000005361] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome that often requires critical care support and remains difficult to diagnose. These guidelines are meant to aid in the early recognition, diagnosis, supportive care, and treatment of patients with hemophagocytic lymphohistiocytosis in ICUs. DATA SOURCES The literature searches were performed with PubMed (MEDLINE). STUDY SELECTION Keywords and medical subject headings terms for literature search included "macrophage activation syndrome," hemophagocytic lymphohistiocytosis," and "hemophagocytic syndrome." DATA EXTRACTION The Histiocyte Society developed these consensus recommendations on the basis of published reports and expert opinions with level of evidence provided for each recommendation. They were endorsed by the Society of Critical Care Medicine. DATA SYNTHESIS Testing for hemophagocytic lymphohistiocytosis should be initiated promptly in all patients admitted to ICUs with an unexplained or disproportionate inflammatory response, especially those with rapid clinical deterioration. Meeting five or more of eight hemophagocytic lymphohistiocytosis 2004 diagnostic criteria serves as a valuable diagnostic tool for hemophagocytic lymphohistiocytosis. Early aggressive critical care interventions are often required to manage the multisystem organ failure associated with hemophagocytic lymphohistiocytosis. Thorough investigation of the underlying triggers of hemophagocytic lymphohistiocytosis, including infections, malignancies, and autoimmune/autoinflammatory diseases, is essential. Early steroid treatment is indicated for patients with familial hemophagocytic lymphohistiocytosis and is often valuable in patients with acquired hemophagocytic lymphohistiocytosis (i.e., secondary hemophagocytic lymphohistiocytosis) without previous therapy, including macrophage activation syndrome (hemophagocytic lymphohistiocytosis secondary to autoimmune/autoinflammatory disease) without persistent or relapsing disease. Steroid treatment should not be delayed, particularly if organ dysfunction is present. In patients with macrophage activation syndrome, whose disease does not sufficiently respond, interleukin-1 inhibition and/or cyclosporine A is recommended. In familial hemophagocytic lymphohistiocytosis and severe, persistent, or relapsing secondary macrophage activation syndrome, the addition of prompt individualized, age-adjusted etoposide treatment is recommended. CONCLUSIONS Further studies are needed to determine optimal treatment for patients with hemophagocytic lymphohistiocytosis in ICUs, including the use of novel and adjunct therapies.
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25
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Wilson-Morkeh H, Frise C, Youngstein T. Haemophagocytic lymphohistiocytosis in pregnancy. Obstet Med 2021; 15:79-90. [DOI: 10.1177/1753495x211011913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.
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Affiliation(s)
- Harold Wilson-Morkeh
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Charlotte Frise
- Fetal-Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- De Swiet’s Obstetric Medicine Centre, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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Benallegue N, Beaudonnet F, Husson B, Moshous D, Van Bogaert P, Deiva K. Neurological involvement in secondary hemophagocytic lymphohistiocytosis in children. Eur J Paediatr Neurol 2021; 34:110-117. [PMID: 34482125 DOI: 10.1016/j.ejpn.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/27/2021] [Accepted: 08/15/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe neurological characteristics and CNS involvement on MRI in secondary hemophagocytic lymphohistiocytosis (sHLH) and differentiate it from primary hemophagocytic lymphohistiocytosis (pHLH) and acute disseminated encephalomyelitis (ADEM). METHODS Nine children with sHLH who had neurological symptoms were retrospectively included. Characteristics of brain MRI were compared to those of 15 children with pHLH and neurological involvement and 44 children with ADEM. RESULTS Three children (33%) presented with isolated neurological symptoms. Neurological signs occurred within one month following Epstein-Barr virus primary infection or systemic juvenile arthritis exacerbation in 8 patients (89%). Eight children (89%) had MRI lesions. sHLH MRI lesions were distinct of those of pHLH by morphology and signal with more frequent hyposignal intensities on T1-weighted sequences (p = 0.01) and well-defined and less fuzzy lesions (p = 0.03). All patients survived and one patient presented severe motor and cognitive disability. CONCLUSION Neurological symptoms of sHLH are non-specific and their outcome is favorable in most of the children. MRI at onset may help to differentiate this condition from pHLH.
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Affiliation(s)
- Nail Benallegue
- Pediatric Department, Nantes University Hospital, Nantes, France.
| | - Frédérique Beaudonnet
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Site Bicêtre, Pediatric Neurology Department, National Reference Centre for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Le Kremlin Bicêtre.
| | - Béatrice Husson
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Site Bicêtre, Pediatric Neurology Department, National Reference Centre for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Le Kremlin Bicêtre.
| | - Despina Moshous
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Laboratory « Genome Dynamics in the Immune System », Imagine Institute Paris, INSERM UMR1163, University of Paris, Paris, France.
| | - Patrick Van Bogaert
- Department of Pediatric Neurology, Angers University Hospital, Angers, France; LARIS Laboratoire Angevin de Recherche en Ingenierie des Systémes, University of Angers, France.
| | - Kumaran Deiva
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Saclay, Site Bicêtre, Pediatric Neurology Department, National Reference Centre for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Le Kremlin Bicêtre; UMR1184 « Immunology of Viral Infections and Autoimmune Diseases », CEA, IDMIT, Faculty of Medicine Paris-Saclay, France.
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Shyu S, Luca D, VandenBussche CJ, Ho CY. Cytomorphologic Features Found in Cerebrospinal Fluid Specimens of Hemophagocytic Lymphohistiocytosis Patients. Am J Clin Pathol 2021; 156:381-390. [PMID: 33624013 DOI: 10.1093/ajcp/aqaa248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Central nervous system involvement is present in 70% of patients with hemophagocytic lymphohistiocytosis (CNS-HLH). CNS-HLH is defined by neurologic deficits, neuroimaging abnormalities, or positive cerebrospinal fluid (CSF) findings. The CSF cytomorphologic spectrum of CNS-HLH, however, has not been well investigated. METHODS A retrospective review was performed on 64 CSF specimens from pediatric and adult patients with HLH. Ten patients had clinicoradiologic evidence of CNS involvement. RESULTS We identified five CSF cytomorphologic patterns: (1) hemophagocytosis, (2) vacuolated macrophages without evidence of hemophagocytosis, (3) monocytes and/or nonvacuolated macrophages, (4) acellular specimens, and (5) bloody specimens. Patterns 1 and 2 were common in CNS-HLH and rare in patients without CNS involvement. The CSF cytomorphologic patterns did not correlate well with WBC counts or protein concentration. CONCLUSIONS Our study offers a comprehensive view of the cytomorphologic features seen in CSF specimens from patients with HLH.
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Affiliation(s)
- Susan Shyu
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Dragos Luca
- Division of Pathology, Children’s National Health System, Washington, DC, USA
| | | | - Cheng-Ying Ho
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
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Stem cell transplantation for children with hemophagocytic lymphohistiocytosis: results from the HLH-2004 study. Blood Adv 2021; 4:3754-3766. [PMID: 32780845 DOI: 10.1182/bloodadvances.2020002101] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/14/2020] [Indexed: 12/14/2022] Open
Abstract
We report the largest prospective study thus far on hematopoietic stem cell transplantation (HSCT) in hemophagocytic lymphohistiocytosis (HLH), a life-threatening hyperinflammatory syndrome comprising familial/genetic HLH (FHL) and secondary HLH. Although all patients with HLH typically need intensive anti-inflammatory therapy, patients with FHL also need HSCT to be cured. In the international HLH-2004 study, 187 children aged <18 years fulfilling the study inclusion criteria (5 of 8 diagnostic criteria, affected sibling, or molecular diagnosis in FHL-causative genes) underwent 209 transplants (2004-2012), defined as indicated in patients with familial/genetic, relapsing, or severe/persistent disease. Five-year overall survival (OS) post-HSCT was 66% (95% confidence interval [CI], 59-72); event-free survival (EFS) was 60% (95% CI, 52-67). Five-year OS was 81% (95% CI, 65-90) for children with a complete response and 59% (95% CI, 48-69) for those with a partial response (hazard ratio [HR], 2.12; 95% CI, 1.06-4.27; P = .035). For children with verified FHL (family history/genetically verified, n = 134), 5-year OS was 71% (95% CI, 62-78) and EFS was 62% (95% CI, 54-70); 5-year OS for children without verified FHL (n = 53) was significantly lower (52%; 95% CI, 38-65) (P = .040; HR, 1.69; 95% CI, 1.03-2.77); they were also significantly older. Notably, 20 (38%) of 53 patients without verified FHL had natural killer cell activity reported as normal at diagnosis, after 2 months, or at HSCT, suggestive of secondary HLH; and in addition 14 (26%) of these 53 children had no evidence of biallelic mutations despite having 3 or 4 FHL genes analyzed (natural killer cell activity not analyzed after 2 months or at HSCT). We conclude that post-HSCT survival in FHL remains suboptimal, and that the FHL diagnosis should be carefully investigated before HSCT. Pretransplant complete remission is beneficial but not mandatory to achieve post-HSCT survival. This trial was registered at www.clinicaltrials.gov as #NCT00426101.
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Fohle E, Afriyie F, Dekowski SS. Central Nervous System Involvement in Adult-Onset Hemophagocytic Lymphohistiocytosis. Cureus 2021; 13:e14792. [PMID: 34084687 PMCID: PMC8166263 DOI: 10.7759/cureus.14792] [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] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease marked by high cytokine levels, uncontrolled lymphocyte, and macrophage proliferation. It is generally a systemic disorder with varying degrees of central nervous system (CNS) involvement, with the vast majority of cases affecting children. We report a case of CNS-HLH in a 51-year-old male who initially presented with fevers, night sweats, fatigue, bilateral arthralgia, and altered mental status. Computed tomography (CT) of the chest, abdomen, and pelvis showed hepatosplenomegaly. Magnetic resonance imaging (MRI) of the brain showed enhancing lesions mainly in the right frontal lobe with a small hemorrhagic focus. An extensive workup for infectious, autoimmune, and neoplastic and genetic etiologies was only significant for cytopenia with markedly elevated C-reactive protein (CRP), ferritin, and lactate dehydrogenase (LDH), in addition to mild triglyceridemia. Bone marrow and liver biopsy revealed hemophagocytosis. Brain biopsy revealed no evidence of malignancy or infection. The patient was treated with high-dose dexamethasone and etoposide and fully recovered with resolution of all of HLH parameters and decrease/resolution of brain lesion. Clinicians should have a high index of suspicion for CNS-HLH in adults who present with sepsis-like illness with fevers, altered mental status, and cytopenia but negative cultures and unusual radiographic cerebral abnormalities so that early diagnosis and treatment can be initiated to prevent end-organ failure and death.
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Affiliation(s)
- Emmanuel Fohle
- Internal Medicine, University of North Dakota, Fargo, USA
| | - Felix Afriyie
- Internal Medicine, East Carolina University/Vidant Medical Center, Greenville, USA
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Elsharkawy A, Assem H, Salama M, Mikhael N, Zeid MY, El Chazli Y. Clinical Characteristics and Outcomes of 101 Children with Hemophagocytic Lymphohistiocytosis: A Four-Year Single-Center Experience from Egypt. Pediatr Hematol Oncol 2021; 38:194-207. [PMID: 33150824 DOI: 10.1080/08880018.2020.1825575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition, arising either due to genetic mutations or from a variety of underlying diseases. This prospective observational study reports the clinical and laboratory data as well as the outcome of pediatric HLH in Egypt. HLH was diagnosed according to the Histiocyte Society HLH-2004 diagnostic criteria conducted at Alexandria University Children's Hospital over four years. One-hundred-one patients were enrolled (44 males and 57 females), and the median age at presentation was 13.1 months (range: 1 day - 181.4 months). Almost 75% of the patients had consanguineous parents, and one-third had a history of an affected family member (HLH or HLH-like illness). The median time interval between the first HLH symptom and diagnosis was 34 days. At diagnosis, patients were preliminarily classified as having primary HLH in 61% of patients and secondary HLH in 39% of patients. The diagnosis was confirmed genetically in 57 patients. Seventy-eight percent of patients received the HLH-94 and HLH-2004 protocols, only seven patients have undergone hematopoietic stem cell transplantation. The overall survival was 26.4% by the end of the study; the most common cause of death was uncontrolled disease activity. This descriptive study, on a large cohort of pediatric HLH in Africa and the Middle East, sheds some light on the epidemiological characteristics of HLH patients and the available diagnostic and therapeutic tools. The mortality rate was considerably high, highlighting the importance of early diagnosis and initiation of appropriate therapy.
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Affiliation(s)
- Asmaa Elsharkawy
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hala Assem
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mostafa Salama
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Neveen Mikhael
- Department of Clinical and chemical pathology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Maha Y Zeid
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yasmine El Chazli
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Castaño-Jaramillo LM, Lugo-Reyes SO, Cruz Muñoz ME, Scheffler-Mendoza SC, Duran McKinster C, Yamazaki-Nakashimada MA, Espinosa-Padilla SE, Saez-de-Ocariz Gutierrez MDM. Diagnostic and therapeutic caveats in Griscelli syndrome. Scand J Immunol 2021; 93:e13034. [PMID: 33660295 DOI: 10.1111/sji.13034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/26/2021] [Indexed: 12/23/2022]
Abstract
Griscelli syndrome (GS) is a rare autosomal recessive disease with characteristic pigment distribution, and there are currently 3 types according to the underlying genetic defect and clinical features. We present the case of a girl born from consanguineous parents who presented with predominant neurologic symptoms, silvery hair and granulomatous skin lesions. Cerebral magnetic resonance revealed diffuse white matter lesions, and central nervous system (CNS) lymphocytic infiltration was suspected. The patient underwent haematopoietic stem cell transplantation with graft failure and autologous reconstitution. She developed elevated liver enzyme with a cholestatic pattern. Multiple liver biopsies revealed centrilobular cholestasis and unspecific portal inflammation that improved with immunomodulatory treatment. She was revealed to have an impaired cytotoxicity in NK cells and a decreased expression of RAB27A. However, no variants were found in the gene. All types of GS present with pigment dilution and irregular pigment clumps that can be seen through light microscopy in hair and skin biopsy. Dermic granulomas and immunodeficiency with infectious and HLH predisposition have been described in GS type 2 (GS2). Neurologic alterations might be seen in GS type 1 (GS1) and GS type 2 (GS2), due to different mechanisms. GS1 presents with neurologic impairment secondary to myosin Va role in neuronal development and synapsis. Meanwhile, GS2 can present with neurologic impairment secondary to SNC HLH. Clinical features and cytotoxicity might aid in differentiating GS1 and GS2, especially since treatment differs.
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Affiliation(s)
| | - Saul O Lugo-Reyes
- Immunodeficiencies Research Unit, Instituto Nacional de Pediatria, Mexico City, Mexico
| | - Mario E Cruz Muñoz
- Molecular Immunology Laboratory. Faculty of Medicine, Universidad Autonoma del Estado de Morelos, Cuernavaca, Mexico
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Taieb G, Kaphan E, Duflos C, Lebrun-Frénay C, Rigau V, Thouvenot E, Duhin-Gand E, Lefaucheur R, Hoang-Xuan K, Coulette S, Ouallet JC, Menjot de Champfleur N, Tranchant C, Picard C, Fusaro M, Sepulveda FE, Labauge P, de Saint Basile G. Hemophagocytic Lymphohistiocytosis Gene Mutations in Adult Patients Presenting With CLIPPERS-Like Syndrome. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/3/e970. [PMID: 33658321 PMCID: PMC7963436 DOI: 10.1212/nxi.0000000000000970] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022]
Abstract
Objective To determine whether adult cases of Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) may be related to familial hemophagocytic lymphohistiocytosis (HLH) causes, we have screened patients with adult-onset CLIPPERS for mutations in primary HLH-associated genes. Methods In our cohort of 36 patients fulfilling the criteria for probable or definite CLIPPERS according to the CLIPPERS-2017 criteria, we conducted a first study on 12 patients who consented to genetic testing. In these 12 patients, systemic HLH criteria were searched, and genetic analysis of 8 genes involved in primary HLH was performed. Results Four definite and 8 probable CLIPPERS were enrolled (n = 12). Mutations involved in HLH were identified in 2 definite and 2 probable CLIPPERS (4/12). Three of them had biallelic PRF1 mutations with reduced perforin expression in natural killer cells. The remaining patient had biallelic UNC13D mutations with cytotoxic lymphocyte impaired degranulation. None of the mutated patients reached the criteria for systemic HLH. During follow-up, 3 of them displayed atypical findings for CLIPPERS, including emergence of systemic non-Hodgkin lymphoma (1/3) and confluent gadolinium-enhancing lesions on brain MRI (3/3). Conclusions In our patients presenting with adult-onset CLIPPERS, one-third have HLH gene mutations. This genetic treatable condition should be searched in patients with CLIPPERS, especially in those presenting with atypical findings.
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Affiliation(s)
- Guillaume Taieb
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France.
| | - Elsa Kaphan
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Claire Duflos
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Christine Lebrun-Frénay
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Valérie Rigau
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Eric Thouvenot
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Emeline Duhin-Gand
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Romain Lefaucheur
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Khe Hoang-Xuan
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Sarah Coulette
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Jean Christophe Ouallet
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Nicolas Menjot de Champfleur
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Christine Tranchant
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Capucine Picard
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Mathieu Fusaro
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Fernando E Sepulveda
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Pierre Labauge
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Geneviève de Saint Basile
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
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Systemic and Nodular Hyperinflammation in a Patient with Refractory Familial Hemophagocytic Lymphohistiocytosis 2. J Clin Immunol 2021; 41:987-991. [PMID: 33570715 PMCID: PMC8896913 DOI: 10.1007/s10875-021-00986-9] [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: 11/12/2020] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
Familial hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome resulting from defective cytotoxicity. A previously healthy 3-month-old female presented with fever, irritability, abdominal distention, and tachypnea. She ultimately met all eight HLH-2004 diagnostic criteria, accompanied by elevated CXCL9. Initial empiric anti-inflammatory treatment included anakinra and IVIg, which stabilized ferritin and cytopenias. She had molecular and genetic confirmation of perforin deficiency and was started on dexamethasone and etoposide per HLH-94. She clinically improved, though CXCL9 and sIL-2Ra remained elevated. She was readmitted at week 8 for relapsed HLH without clear trigger and HLH-94 induction therapy was reinitiated. Her systemic HLH symptoms failed to respond and she soon developed symptomatic CNS HLH. She was incidentally found to have multifocal lung and kidney nodules, which were sterile and consisted largely of histiocytes and activated, oligoclonal CD8 T cells. The patient had a laboratory response to salvage therapy with alemtuzumab and emapalumab, but progressive neurologic decline led to withdrawal of care. This report highlights HLH foci manifest as pulmonary/renal nodules, demonstrates the utility of monitoring an array of HLH biomarkers, and suggests possible benefit of earlier salvage therapy.
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Janke LJ, Imai DM, Tillman H, Doty R, Hoenerhoff MJ, Xu JJ, Freeman Z, Allen P, Fowlkes NW, Iacobucci I, Dickerson K, Mullighan CG, Vogel P, Rehg JE. Development of Mast Cell and Eosinophil Hyperplasia and HLH/MAS-Like Disease in NSG-SGM3 Mice Receiving Human CD34+ Hematopoietic Stem Cells or Patient-Derived Leukemia Xenografts. Vet Pathol 2021; 58:181-204. [PMID: 33208054 PMCID: PMC8414369 DOI: 10.1177/0300985820970144] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Immunocompromised mouse strains expressing human transgenes are being increasingly used in biomedical research. The genetic modifications in these mice cause various cellular responses, resulting in histologic features unique to each strain. The NSG-SGM3 mouse strain is similar to the commonly used NSG (NOD scid gamma) strain but expresses human transgenes encoding stem cell factor (also known as KIT ligand), granulocyte-macrophage colony-stimulating factor, and interleukin 3. This report describes 3 histopathologic features seen in these mice when they are unmanipulated or after transplantation with human CD34+ hematopoietic stem cells (HSCs), virally transduced hCD34+ HSCs, or a leukemia patient-derived xenograft. The first feature is mast cell hyperplasia: unmanipulated, naïve mice develop periductular pancreatic aggregates of murine mast cells, whereas mice given the aforementioned human cells develop a proliferative infiltrative interstitial pancreatic mast cell hyperplasia but with human mast cells. The second feature is the predisposition of NSG-SGM3 mice given these human cells to develop eosinophil hyperplasia. The third feature, secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS)-like disease, is the most pronounced in both its clinical and histopathologic presentations. As part of this disease, a small number of mice also have histiocytic infiltration of the brain and spinal cord with subsequent neurologic or vestibular signs. The presence of any of these features can confound accurate histopathologic interpretation; therefore, it is important to recognize them as strain characteristics and to differentiate them from what may be experimentally induced in the model being studied.
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Affiliation(s)
- Laura J. Janke
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Denise M. Imai
- Comparative Pathology Laboratory, University of California, Davis, California, USA
| | - Heather Tillman
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | | | - Mark J. Hoenerhoff
- In Vivo Animal Core, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Unit for Laboratory Animal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jiajie J. Xu
- Unit for Laboratory Animal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Zach Freeman
- Unit for Laboratory Animal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Portia Allen
- Unit for Laboratory Animal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Natalie Wall Fowlkes
- Department of Veterinary Medicine and Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ilaria Iacobucci
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kirsten Dickerson
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Charles G. Mullighan
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Hematological Malignancies Program, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Peter Vogel
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jerold E. Rehg
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Cheng H, Chen D, Peng X, Wu P, Jiang L, Hu Y. Clinical characteristics of Epstein-Barr virus infection in the pediatric nervous system. BMC Infect Dis 2020; 20:886. [PMID: 33238935 PMCID: PMC7691062 DOI: 10.1186/s12879-020-05623-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To investigate the clinical characteristics of Epstein-Barr virus (EBV) infection in the pediatric nervous system (NS). METHODS We retrospectively analyzed the clinical data and follow-up results of 89 children with neurological damage caused by EBV who were hospitalized in the children's hospital of Chongqing Medical University from January 2008 to April 2019. RESULTS EBV infection of the NS can occur at any time of the year. The highest incidence was seen in the age group of 0-4 years. Fever is the main clinical feature (74/89, 83.1%). The main clinical types were encephalitis/meningoencephalitis (64/89, 71.9%), acute myelitis (2/89, 2.2%), acute disseminated encephalomyelitis (ADEM) (3/89, 3.4%), Guillain-Barré Syndrome (GBS) (15/89, 16.9%), neurological damage caused by EBV-hemophagocytic lymphohistiocytosis (EBV-HLH) (4/89, 4.5%), and NS-post-transplant lymphoproliferative disorder (NS-PTLD) (1/89, 1.1%). Anti-N-methyl-D-aspartate receptor encephalitis was found during the convalescence of EBV encephalitis. EBV encephalitis/meningitis showed no symptoms of tonsillitis, lymph node enlargement, skin rash, hepatosplenomegaly. Acute motor axonal neuropathy is the chief complication in GBS caused by EBV. CONCLUSION There were significant differences in neurological complications caused by EBV. The prognosis of EBV infection in the NS is generally good. These illnesses are often self-limiting. A few cases may show residual sequelae.
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Affiliation(s)
- Huan Cheng
- Department of Neurology, Children’s Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Doudou Chen
- Department of Neurology, Children’s Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiaoling Peng
- Division of Science and Technology, Beijing Normal University-Hongkong Baptist University United International College, Zhuhai, China
| | - Peng Wu
- Department of Neurology, Children’s Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children’s Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yue Hu
- Department of Neurology, Children’s Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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36
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Parisi C, Candela-Cantó S, Serrano M, Catala A, Aparicio J, Hinojosa J. Life-threatening secondary hemophagocytic lymphohistiocytosis following vagal nerve stimulator infection in a child with CHD2 myoclonic encephalopathy: a case report. Childs Nerv Syst 2020; 36:2851-2856. [PMID: 32170405 DOI: 10.1007/s00381-020-04558-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/27/2020] [Indexed: 01/28/2023]
Abstract
Vagus nerve stimulation (VNS) is a surgical treatment available for patients affected by generalized refractory epilepsy. The authors report the case of a 15-year-old girl affected by CHD2-related myoclonic encephalopathy and BLM haploinsufficiency due to a deletion of 15q25.3q26.2 region, who suffered from secondary hemophagocytic lymphohistiocytosis (SHLH) after a VNS wound infection. SHLH has sporadically been described in epileptic patients. Based on indirect evidence that shows immune dysregulation in patients with CHD2 mutations and BLM mutations, we hypothesize that the genetic background of this patient may have played a critical role in the development of the syndrome.
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Affiliation(s)
- Cristiano Parisi
- Neurosurgery Unit, Neuroscience Department, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
| | - Santiago Candela-Cantó
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Mercedes Serrano
- Neurology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Albert Catala
- Department of Hematology, Institut de Recerca Hospital Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Javier Aparicio
- Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,Neurology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Barcelona, Spain
| | - José Hinojosa
- Pediatric Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.,Pediatric Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
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Ma W, Li XJ, Li W, Xiao L, Ji XJ, Xu Y. MRI findings of central nervous system involvement in children with haemophagocytic lymphohistiocytosis: correlation with clinical biochemical tests. Clin Radiol 2020; 76:159.e9-159.e17. [PMID: 33036779 DOI: 10.1016/j.crad.2020.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/09/2020] [Indexed: 11/16/2022]
Abstract
AIM To investigate the brain magnetic resonance imaging (MRI) features of children with haemophagocytic lymphohistiocytosis (HLH) with central nervous system (CNS) involvement, and to investigate the correlation with clinical biochemical tests. MATERIAL AND METHODS Clinical and MRI data were collected from 118 children with HLH-CNS between January 2012 and June 2019. Patients were grouped according to their MRI findings, and statistical methods were used to test for correlations between the MRI findings and biochemical variables. RESULTS Patients were divided into three groups, including normal appearance (Group 1, 17/118), diffuse parenchymal volume loss (Group 2, 44/118), and brain parenchyma lesions (Group 3, 57/118) containing three subtypes of brain lesions and HLH-CNS complications. Comparing biochemical values among the three groups revealed a significant difference for all values (p<0.05), except for cell counts in the cerebrospinal fluid (CSF). A pairwise comparison further showed significant inter-group differences for most of the variables. Spearman's rank correlation coefficient also demonstrated that CSF cell counts (r=0.193, p=0.036), CSF microprotein content (r=0.379, p<0.001), serum aspartate aminotransferase (AST; r=0.521, p<0.001), serum lactate dehydrogenase (LDH; r=0.514, p<0.001) and activated partial thromboplastin time (APTT; r=0.326, p<0.001) correlated positively with the MRI groups, while platelet count (PLT; r=-0.633, p<0.001) and plasma fibrinogen (FIB; r=-0.258, p=0.005) correlated negatively. CONCLUSION Classification of brain MRI findings of HLH-CNS correlates well with the results of several key biochemical tests. Brain MRI is a promising method to elucidate illness severity and clinical outcomes.
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Affiliation(s)
- W Ma
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - X J Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - W Li
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - L Xiao
- Clinical Laboratory, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - X J Ji
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Y Xu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China.
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Ma H, Zhang R, Zhang L, Wei A, Zhao X, Yang Y, Liu W, Li Z, Qin M, Wang T. Treatment of pediatric primary hemophagocytic lymphohistiocytosis with the HLH-94/2004 regimens and hematopoietic stem cell transplantation in China. Ann Hematol 2020; 99:2255-2263. [PMID: 32766934 DOI: 10.1007/s00277-020-04209-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022]
Abstract
We aimed to clarify the clinical characteristics, prognostic factors, and effectiveness of the HLH-94/2004 regimens and hematopoietic stem cell transplantation (HSCT) in pediatric patients with primary hemophagocytic lymphohistiocytosis (pHLH) in China. A retrospective analysis was performed on 38 patients with pHLH at Beijing Children's Hospital. PRF1 (34.2%) and UNC13D (31.6%) were the most common mutations in the pHLH. Thirty-eight patients were treated with the HLH-94/2004 regimens after diagnosis. Twenty-six patients (72.2%) responded to first-line treatment (complete response: 55.5%, partial response: 16.7%). The median survival time was 23 months. The overall survival (OS) rate at 3 years was 74.7%. There was no significant difference in the response rate (72% vs. 63.6%, P = 0.703) or 3-year OS (83.6% vs. 66.7%, P = 0.443) between the patients treated with the HLH-94 regimen and those treated with the HLH-2004 regimen. The incidences of all side effects in patients treated with the HLH-94 or HLH-2004 regimen were 32.0% and 18.2%, respectively (P = 0.394). Among 15 patients treated with HSCT, neither the preconditioning regimen nor the donor type affected patient prognosis (P = 0.205 and P = 0.161, respectively). The disease status (remission or nonremission) before preconditioning did not affect prognosis or the incidence of GVHD. Furthermore, a higher bilirubin level (≥ 30 μmol/L) was correlated with a poorer prognosis in pHLH patients (P = 0.026). The effectiveness rates of the HLH-94 and HLH-2004 regimens, chemotherapy, and HSCT were similar in pHLH patients. A bilirubin level ≥ 30 μmol/L might be an adverse prognostic factor in pHLH.
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Affiliation(s)
- Honghao Ma
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Rui Zhang
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Liping Zhang
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Ang Wei
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Xiaoxi Zhao
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Ying Yang
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China
| | - Wei Liu
- Department of Hematology, Children's Hospital of Zhengzhou City, Zhengzhou, 450053, China
| | - Zhigang Li
- Hematology and Oncology Laboratory, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Pediatric Research Institute, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China.
| | - Maoquan Qin
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China.
| | - Tianyou Wang
- Department of Hematology and Oncology, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing Children's Hospital Affiliated to Capital Medical University, Nanlishi Road No. 56, Xicheng District, Beijing, 100045, People's Republic of China.
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled and excessive immune responses with high mortality. We aimed to define mortality-related parameters in HLH secondary to primary immunodeficiency (PID). A total of 28 patients with HLH between the years 2013 and 2017 were enrolled in the study. The patients were evaluated in 2 groups including PID with hypopigmentation (n=7) (Chédiak-Higashi syndrome [CHS] and Griscelli syndrome type 2 [GS2]) and other PIDs (n=21). The median age of the study population was 23 (4.3 to 117.0) months at the time of the diagnosis of HLH. Central nervous system involvement was recorded in 7 (GS2/CHS patients [n=4], other PIDs [n=3], P=0.026), and death was observed in 9 patients (GS2/CHS patients [n=1], other PIDs [n=8], P=0.371). Five patients (3 GS2/CHS and 2 other PID patients) underwent hematopoietic stem cell transplantation. Low serum albumin level was the only variable associated with the mortality and albumin levels less than the cut-off value of 3.07 g/dL increased mortality 5.8 times in patients with HLH secondary to PID. We presented a single-center experience consisting of patients with HLH secondary to PID with a mortality rate of 32.1%. Hypoalbuminemia was the only risk factor to increase the overall mortality rate of HLH.
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Neuroinflammatory Disease as an Isolated Manifestation of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2020; 40:901-916. [PMID: 32638196 DOI: 10.1007/s10875-020-00814-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023]
Abstract
Isolated neuroinflammatory disease has been described in case reports of familial hemophagocytic lymphohistiocytosis (FHL), but the clinical spectrum of disease manifestations, response to therapy and prognosis remain poorly defined. We combined an international survey with a literature search to identify FHL patients with (i) initial presentation with isolated neurological symptoms; (ii) absence of cytopenia and splenomegaly at presentation; and (iii) systemic HLH features no earlier than 3 months after neurological presentation. Thirty-eight (20 unreported) patients were identified with initial diagnoses including acute demyelinating encephalopathy, leukoencephalopathy, CNS vasculitis, multiple sclerosis, and encephalitis. Median age at presentation was 6.5 years, most commonly with ataxia/gait disturbance (75%) and seizures (53%). Diffuse multifocal white matter changes (79%) and cerebellar involvement (61%) were common MRI findings. CSF cell count and protein were increased in 22/29 and 15/29 patients, respectively. Fourteen patients progressed to systemic inflammatory disease fulfilling HLH-2004 criteria at a mean of 36.9 months after initial neurological presentation. Mutations were detected in PRF1 in 23 patients (61%), RAB27A in 10 (26%), UNC13D in 3 (8%), LYST in 1 (3%), and STXBP2 in 1 (3%) with a mean interval to diagnosis of 28.3 months. Among 19 patients who underwent HSCT, 11 neurologically improved, 4 were stable, one relapsed, and 3 died. Among 14 non-transplanted patients, only 3 improved or had stable disease, one relapsed, and 10 died. Isolated CNS-HLH is a rare and often overlooked cause of inflammatory brain disease. HLH-directed therapy followed by HSCT seems to improve survival and outcome.
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Mitchell R. Hematopoietic Stem Cell Transplantation Beyond Severe Combined Immunodeficiency: Seeking a Cure for Primary Immunodeficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:776-785. [PMID: 30832892 DOI: 10.1016/j.jaip.2018.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 12/27/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) can provide definitive therapy for patients with primary immunodeficiency disease (PIDD). Modern HSCT techniques and supportive care have significantly improved outcomes for patients with PIDD. This review examines current HSCT practice for PIDD other than severe combined immunodeficiency, and explores indications, risks, and long-term outcomes for this group of challenging diseases.
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Affiliation(s)
- Richard Mitchell
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia; School of Women and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.
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Yoon HS. A Recent Update on Histiocytic Disorder in Children: Focus on Diagnosis and Treatment. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2020. [DOI: 10.15264/cpho.2020.27.1.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hoi Soo Yoon
- Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Korea
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Hematopoietic stem cell transplantation in children with Griscelli syndrome type 2: a single-center report on 35 patients. Bone Marrow Transplant 2020; 55:2026-2034. [PMID: 32286505 DOI: 10.1038/s41409-020-0885-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/17/2020] [Accepted: 03/23/2020] [Indexed: 01/25/2023]
Abstract
In 2010, we reported the outcome of hematopoietic stem cell transplantation (HSCT) in 11 children with Griscelli syndrome type 2 (GS2). We report here the update on this cohort to include 35 patients. Twenty-seven (77%) patients received conditioning regimen including busulfan, cyclophosphamide with etoposide. Eight (23%) were given busulfan, fludarabine. Thiotepa was added to busulfan and fludarabine regimen in two patients; one received haploidentical marrow and one unrelated cord blood. Posttransplant clinical events included veno-occlusive disease (n = 7), acute (n = 8), or chronic (n = 1) graft-versus-host disease II-IV. With a mortality rate of 37.1% (n = 13) and a median follow-up of 87.7 months of the survivors, 5-year cumulative probability of overall survival (OS) for our cohort of patients was 62.7% (±8.2%). Cumulative probability of 5-year OS was significantly better in those who did not have hemophagocytic lymphohistiocytosis (HLH) prior to HSCT (100% vs. 53.3 ± 9.5%, P value: 0.042). Of the 16 patients with neurologic involvement before HSCT, 8 survived and 3 presented sequelae. OS at 5-year was 50 ± 12.5% and 73.3 ± 10.2% (P value: 0.320) in patients with and without CNS involvement, respectively. In conclusion, HSCT in patients with GS2 is potentially curative with long-term disease-free survival. Early HSCT before the development of the accelerated phase is associated with a better outcome.
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Feng WX, Yang XY, Li JW, Gong S, Wu Y, Zhang WH, Han TL, Zhuo XW, Ding CH, Fang F. Neurologic Manifestations as Initial Clinical Presentation of Familial Hemophagocytic Lymphohistiocytosis Type2 Due to PRF1 Mutation in Chinese Pediatric Patients. Front Genet 2020; 11:126. [PMID: 32194620 PMCID: PMC7064636 DOI: 10.3389/fgene.2020.00126] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 02/03/2020] [Indexed: 12/20/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis Type 2 (FHL2) associated central nervous system (CNS) involvement is less understood in children, especially when considering neurologic manifestations as part of the initial presentation. We conducted a retrospective review of the clinical manifestations and genetic abnormality of four Han Chinese children with FHL2 who were patients at the neurology department of Beijing Children’s Hospital from November 2015 to October 2018. These four patients initially manifested CNS symptoms in their disease presentation, and all four patients were misdiagnosed as having ademyelinating disease, such as acute disseminated encephalomyelitis and multiple sclerosis. Given these misdiagnoses, it is important that general physicians and pediatricians maintain awareness of the possibility of FHL2 as a differential diagnosis. These four cases included neurologic manifestations including seizures, ataxia, spasticity, gait disorder, and coma. Bilateral abnormal signals in the cerebrum, including in white matter, gray matter, and junctions were discovered. Enhanced magnetic resonance imaging (MRI) in these patients showed spot or ring enhancement and/or hemorrhage. These patients all possessed a compound heterozygote mutation PRF1 gene. Whole exome sequencing analysis revealed seven different mutations (three novel mutations) spread over the PRF1 gene and a heterozygous missense mutation c.1349C > T [p.T450M] that was present in two patients. Three novel mutations, c.634T > C[p.Y212H], c.1083_1094del[p.361_364del], and c.1306G > T [p.D436Y], were discovered and through in silico analysis were discovered to be deleterious. Neurologic manifestations were the initial symptoms of FHL2 in these patients in addition to the expected leukopenia and hepatosplenomegaly. Whole exome sequencing of PRF1 for patients with similar presentations would facilitate prompt and accurate diagnosis and treatment.
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Affiliation(s)
- Wei-Xing Feng
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Xin-Ying Yang
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Jiu-Wei Li
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Shuai Gong
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Yun Wu
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Wei-Hua Zhang
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Tong-Li Han
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Xiu-Wei Zhuo
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Chang-Hong Ding
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
| | - Fang Fang
- Neurology Department, National Center for Children's Health China, Beijing Children Hospital affiliated to Capital Medical University, Beijing, China
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45
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Central nervous system-restricted familial hemophagocytic lymphohistiocytosis responds to hematopoietic cell transplantation. Blood Adv 2020; 3:503-507. [PMID: 30760465 DOI: 10.1182/bloodadvances.2018027417] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/03/2019] [Indexed: 01/22/2023] Open
Abstract
Key Points
Familial HLH can present as chronic isolated neuroinflammation. CNS-isolated HLH responds to hematopoietic cell transplantation.
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46
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Nassar SM, AlBattah MA, Bukhari AA, Alslimah A, Nahass AA. Status Epilepticus as a Consequence of Hemophagocytic Lymphohistiocytosis in a Previously Healthy Infant. Cureus 2020; 12:e6824. [PMID: 32042537 PMCID: PMC6996086 DOI: 10.7759/cureus.6824] [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] [Indexed: 12/02/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal entity with an incidence rate of 1.2 cases per million people per year. HLH is explained as a highly destructive inflammatory consequence of rampant hypercytokinemia due to excessive lymphocyte-mediated activation of macrophages and histiocytes. Primary HLH is a product of genetic dysfunction and could be familial (five subtypes), syndromic immunodeficiency, or as a consequence of mutations predisposing a person to Epstein Barr Virus (EBV) infection. With secondary HLH, there is an identifiable cause provoking the inflammatory reaction, whether it is an infection, an autoimmune disease, or malignancy (particularly hematological). As a result of widespread cytokine deposition, systemic manifestations are seen with a variety of manifestations that can vary between cases. This is a case of a patient who initially presented to the emergency department with fever, altered mentation, and gastroenteritis. Initial investigations showed non-anion gap metabolic acidosis, high white cell count, and deteriorating renal function. Further laboratory tests, bone marrow biopsies, and neurological imaging were conducted throughout the course of admission as the patient further deteriorated systemically. However, it's important to note the abundant neurological manifestations with a worsening level of consciousness and seizures, some of which were categorized as status epilepticus.
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Affiliation(s)
- Saeed M Nassar
- Pediatric Intensive Care Unit, King Khaled University Hospital, Riyadh, SAU
| | - Muath A AlBattah
- Pediatric Intensive Care Unit, King Khalid University Hospital, Riyadh, SAU
| | - Ahmad A Bukhari
- Pediatric Intensive Care Unit, King Khaled University Hospital, Riyadh, SAU
| | - Aryaf Alslimah
- Pediatric Intensive Care Unit, King Saud University, Riyadh, SAU
| | - Assalh A Nahass
- Pediatric Intensive Care Unit, King Saud University, Riyadh, SAU
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47
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Memon F, Ahmed J, Malik F, Ahmad J, Memon DA. Adult-onset Primary Hemophagocytic Lymphohistiocytosis: Reporting a Rare Case with Review of Literature. Cureus 2020; 12:e6723. [PMID: 32133251 PMCID: PMC7034735 DOI: 10.7759/cureus.6723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, aggressive hematological syndrome. It is caused by an increased and unchecked proliferation of T lymphocytes and histiocytes. These cells secrete a large number of inflammatory cytokines and infiltrate various tissues causing multi-organ system failure. HLH may be primary or associated with different types of infections, autoimmune disorders, or malignancies. Primary or familial HLH is fatal and is frequently considered a disorder of infants and young children. Only a few cases of primary HLH have been reported in adults. We present a case of a 37-year-old man who presented with fever, pancytopenia, and hepatosplenomegaly. Lymph node biopsy showed collections of histiocytes with lymphoplasmacytic cells. After excluding all the secondary causes a final diagnosis of primary HLH was made. The patient was started on HLH-2004 protocol (etoposide, cyclosporin A, dexamethasone) along with empiric antituberculous drugs as necrotic granulomas were also noted in the biopsy. HLH has a very poor prognosis and familiarity with clinical symptoms, and diagnostic criteria can aid in timely diagnosis.
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Affiliation(s)
- Fatima Memon
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Jawad Ahmed
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Farheen Malik
- Pediatrics, Dow University of Health Sciences, Karachi, PAK
| | - Junaid Ahmad
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
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49
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Mehra B, Aggarwal V, Kumar P, Kundal M, Gupta D, Kumar A, Dugaya SK. COVID-19-associated Severe Multisystem Inflammatory Syndrome in Children with Encephalopathy and Neuropathy in an Adolescent Girl with the Successful Outcome: An Unusual Presentation. Indian J Crit Care Med 2020; 24:1276-1278. [PMID: 33446986 PMCID: PMC7775929 DOI: 10.5005/jp-journals-10071-23685] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the coronavirus disease 2019 (COVID-19) pandemic. This hyperinflammatory syndrome usually presents with multiorgan dysfunction, predominantly affecting cardiovascular, mucocutaneous, and gastrointestinal systems. However, few children have mild neurological symptoms at admission. Till now, severe neurological manifestations as a part of this spectrum have hardly been reported. This case report describes an adolescent girl with severe MIS-C who presented with multiorgan failure and suffered dual neurological insult, involving both the central and peripheral nervous systems. How to cite this article: Mehra B, Aggarwal V, Kumar P, Kundal M, Gupta D, Kumar A, et al. COVID-19-associated Severe Multisystem Inflammatory Syndrome in Children with Encephalopathy and Neuropathy in an Adolescent Girl with the Successful Outcome: An Unusual Presentation. Indian J Crit Care Med 2020;24(12):1276-1278.
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Affiliation(s)
- Bharat Mehra
- Department of Pediatric Intensive Care, Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India
| | - Vyom Aggarwal
- Department of Pediatrics, Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India
| | - Praveen Kumar
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Mohan Kundal
- Department of Pediatrics, Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India
| | - Dhiren Gupta
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Kumar
- Department of Pediatrics, Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India
| | - Sandeep K Dugaya
- Department of Pediatrics, Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India
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50
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Wang Y, Camelo-Piragua S, Abdullah A, Ibrahim M, Parmar HA. Neuroimaging features of CNS histiocytosis syndromes. Clin Imaging 2019; 60:131-140. [PMID: 31874337 DOI: 10.1016/j.clinimag.2019.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 01/24/2023]
Abstract
Histiocytosis syndromes (HS) are group of heterogeneous disorders characterized by abnormal accumulation and infiltration of histiocytes, cells derived from hematopoietic cells of monocyte/macrophage lineage. Overall these disorders are rare. When they do occur they involve many organ systems including the central nervous system (CNS). While imaging findings can provide important clues, diagnosis of this disorder is challenging and definitive diagnosis often necessitates pathologic examination. In this review, we describe imaging features of HS involving the CNS, with the aim to increase our understanding of these disorders. The entities discussed in this review will include: Langerhans cell histiocytosis (LCH), Rosai-Dorfman Disease (RDD), Erdheim Chester Disease (ECD), hemophagocytic lymphohistiocytosis (HLH), and crystal-storing histiocytosis (CSH).
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Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Sandra Camelo-Piragua
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Asif Abdullah
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Mohannad Ibrahim
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Hemant A Parmar
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America.
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