1
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Chen Y, Huang X, Chen H, Tong J, Huang L, Su J, Deng L. A Case Report of Pregnancy Complicated with Primary Hemophagocytic Lymphohistiocytosis. Int J Womens Health 2024; 16:843-851. [PMID: 38774152 PMCID: PMC11107908 DOI: 10.2147/ijwh.s460352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/10/2024] [Indexed: 05/24/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome characterized by excessive activation of NK cells and cytotoxic T lymphocytes, subsequently leading to macrophage activation and increased cytokine production. Misdiagnosis due to nonspecific clinical presentations and inadequate understanding of the disease can significantly jeopardize the safety of both the mother and the infant. We report a case of pregnancy combined with HLH and conduct a literature review to provide insights into the diagnosis and treatment of pregnancy-related HLH. Case Presentation We discussed a case of a pregnant woman with persistent postpartum fever, serum ferritin, and elevated liver function, who failed to respond to repeated anti-infective therapy and was diagnosed with HLH after multidisciplinary diagnostic treatment. We gave dexamethasone treatment, and the patient's temperature and blood cells quickly returned to normal. Finally, exome sequencing revealed heterozygous variation in UNC13D gene, so we considered this case as pregnancy combined with primary HLH (pHLH). Conclusion We report the case of HLH diagnosed during pregnancy and show that early diagnosis and timely intervention can prevent rapid disease progression, reduce maternal mortality rates, and improve survival rates. Additionally, molecular genetic testing can confirm pathogenic gene mutations, providing essential genetic counseling for patients with pHLH who plan to conceive a healthy child.
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Affiliation(s)
- Yan Chen
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Xiaohuan Huang
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Hongfei Chen
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Junru Tong
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Lingling Huang
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Junyou Su
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
| | - Li Deng
- Department of Obstetrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530007, People’s Republic of China
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2
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Wise L, Zell M. Adult-onset Still's disease complicated by macrophage activation syndrome during pregnancy: a case-based review. Clin Rheumatol 2023; 42:3159-3166. [PMID: 37322269 PMCID: PMC10587217 DOI: 10.1007/s10067-023-06664-y] [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: 03/04/2023] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023]
Abstract
Adult-onset Still's disease is a rare, systemic inflammatory rheumatic disease characterized by recurrent fevers, arthritis, and an evanescent rash. One of the most serious hematologic derangements that can be seen with adult-onset Still's disease is macrophage activation syndrome. Macrophage activation syndrome is characterized by activation of lymphocytes, resulting in a cytokine storm and hemophagocytosis in the bone marrow, along with multi-organ failure. Adult-onset Still's disease with macrophage activation syndrome first presenting during pregnancy is exceptionally rare; here, we report two unique cases of such a presentation and review the pertinent literature. Both of our cases presented critically ill with end-organ failure, and responded to immunosuppression; fetal demise was present in one and an emergency caesarean section with a viable fetus was performed in the other patient. Maternal outcomes were favorable in both cases and both patients did well long-term with systemic therapy. Systemic immunosuppression, particularly anti-IL1 therapy, may be considered as treatment for this rare and life-threatening condition when presenting during pregnancy.
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Affiliation(s)
- Leanna Wise
- Division of Rheumatology, Department of Internal Medicine, Keck School of Medicine, University of Southern California, 2020 Zonal Ave. IRD 431, CA 90033 Los Angeles, USA
| | - Monica Zell
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
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3
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Thompson A, Banerjee S, Churchill D, Knight M. Haemophagocytic lymphohistiocytosis in pregnancy and the postpartum period: A retrospective case series analysis. NIHR OPEN RESEARCH 2023; 3:12. [PMID: 37881456 PMCID: PMC10593314 DOI: 10.3310/nihropenres.13339.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 10/27/2023]
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is an extremely rare condition characterised by excessive immune activation leading to haemophagocytic activity and has seldom been reported in pregnancy. HLH manifests as relapsing fevers with features of multi- organ failure and has a high mortality. Methods A retrospective case series analysis using national data from MBRRACE-UK maternal death reports (n=5) and case notes from patients diagnosed with HLH during pregnancy at New Cross Hospital, Wolverhampton (n=2) between 2012 and 2021. Results A total of seven cases were included. Cases uniformly presented with fever and experienced prodromal illnesses consisting of lymphadenopathy, fevers, and malaise. Gestation at presentation ranged from 9/40 to 11 months postpartum. All patients had multiple cytopaenias. Other common features included elevated liver enzymes (n=5), hyperferritinaemia (n=5), splenomegaly (n=4), hypofibrinogenemia (n=4) and elevated soluble interleukin-2 receptor α (CD25) levels (n=3). Underlying causes were identified in four cases. Median time from presentation to diagnosis was 35 days. Bone marrow biopsy was diagnostic in a majority of cases. Corticosteroids and ciclosporin were the most frequently used treatments. In some cases early delivery by caesarean section or termination of pregnancy was necessary to permit maternal treatment. Progression to multi-organ failure resulting in maternal death occurred in five cases: two cases survived. Pregnancy outcomes were: livebirth at term (n=2), preterm livebirth (n=3), termination of pregnancy (n=1), and miscarriage (n=1). Of the surviving infants, one had bone marrow suppression with anaemia at birth and sensorineural deafness. Conclusions Due to the rarity of the condition, diagnosis is often delayed. In view of the high mortality, clinicians should consider HLH early when reviewing pregnant patients with unexplained pyrexia and multi-organ dysfunction. Early involvement of haematology should be sought, as prompt diagnosis is crucial for meaningful attempts at curative therapy. Important treatment considerations include fetal viability, maternal condition and treatment toxicity.
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Affiliation(s)
- Amy Thompson
- Obstetrics and Gynaecology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Sudipta Banerjee
- Obstetrics and Gynaecology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - David Churchill
- Obstetrics and Gynaecology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Marian Knight
- Maternal and Child Population Health, National Perinatal Epidemiology Unit (NPEU) Nuffield Department of Population Health, Oxford, OX3 7LF, UK
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4
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Simard C, Tardif ML. Hemophagocytic lymphohistiocytosis in pregnancy evolving towards fulminant hepatitis. Obstet Med 2022; 15:208-211. [PMID: 36262816 PMCID: PMC9574453 DOI: 10.1177/1753495x21999914] [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: 11/19/2020] [Revised: 11/19/2020] [Accepted: 02/09/2021] [Indexed: 09/03/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis is a rare disorder, especially in pregnancy, characterized by excessive immune activation leading to hemophagocytic activity. Case Report A 34-year-old woman presented at 31 weeks' gestation with fever, cytopenias, hyperferritinemia and fulminant hepatitis. Bone marrow biopsy was non-contributory, and no trigger was identified. Liver biopsy confirmed the diagnosis of hemophagocytic lymphohistiocytosis, and she received dexamethasone and etoposide, which was changed to anakinra to allow breastfeeding. Prompt diagnosis and treatment of hemophagocytic lymphohistiocytosis is crucial to the survival of pregnant women, but no consensus exists regarding the most appropriate therapy during pregnancy. Conclusion Hemophagocytic lymphohistiocytosis is life-threatening and associated with significant morbidity and mortality. Important treatment considerations in pregnancy include maternal health, fetal prematurity and treatment toxicity. Anakinra has been successfully used in pregnancy and provides a promising alternative.
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Affiliation(s)
- Camille Simard
- Department of Medicine, McGill University, Montreal,
Canada
| | - Marie-Lou Tardif
- Division of Obstetric Medicine, Department of Obstetrics and
Gynecology, CHU Sainte-Justine, Montreal, Canada
- Department of Medicine, Université de Montréal, Montreal,
Canada
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5
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Ren W, Yang S, Liu H, Pan Z, Li Z, Qiao P, Ma H. Case report and literature review: Hemophagocytic lymphohistiocytosis in a pregnant woman with systemic lupus erythematosus with Syntaxin 11 gene defect. Front Oncol 2022; 12:937494. [PMID: 35965579 PMCID: PMC9367683 DOI: 10.3389/fonc.2022.937494] [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: 05/06/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is an extremely rare occurrence during pregnancy. Early recognition of its signs and symptoms is critical for early intervention, and delays in diagnosis may be life-threatening. A 23-year-old nulliparous woman presented with a persistent fever as high as 39°C with bilateral edema of the lower limbs at 24 weeks of gestation. Typical laboratory findings included pancytopenia, high triglycerides, ferritin, transaminases, bilirubin, and hypoproteinemia. Active systemic lupus erythematosus was diagnosed using an autoimmune work-up and a Systemic Lupus Erythematosus Disease Activity Index 2000 score of 17 points. Her bone marrow aspirate revealed prominent hemophagocytosis; hence, HLH was confirmed. Genetic tests showed mutations in Syntaxin 11 mutations. Considering the potential impact of drugs on the fetus, the patient and her family members chose to terminate the pregnancy through medical induction of labor. Afterwards, her condition improved with immunosuppressive therapy.
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Affiliation(s)
- Wei Ren
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Siyuan Yang
- College of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Haiying Liu
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhenglun Pan
- Department of Rheumatism and Immunology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhao Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Peng Qiao
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Peng Qiao, ; Hui Ma,
| | - Hui Ma
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Peng Qiao, ; Hui Ma,
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6
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Fávero Vanraes L, Beckers V, Van Berkel K, Gucciardo L, Faron G. Haemophagocytic lymphohistiocytosis during pregnancy: a case presentation and literature review. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disorder of the immune system that typically occurs in the paediatric population. Diagnosing this rare disease in the adult population is challenging, particularly during pregnancy.
Case presentation
We present a case of a gravid patient developing HLH at week 13 of gestation undergoing a medical termination of pregnancy at 27 weeks due to anhydramnios and associated stopped foetal growth.
Conclusions
Disease triggers could vary from a simple viral infection to the pregnancy as such causing the disorder. Treatment should benefit the mother and limit the foetal harm.
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Affiliation(s)
- Larissa Fávero Vanraes
- Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Veerle Beckers
- Division of Haematology, Department of Internal Medicine , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Kim Van Berkel
- Department of Medical Genetics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Leonardo Gucciardo
- Division of Prenatal Medicine and Obstetrics, Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Gilles Faron
- Division of Prenatal Medicine and Obstetrics, Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
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7
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Sun L, Li P, Pang B, Wu P, Wang R. Gestational Psittacosis With Secondary Hemophagocytic Syndrome: A Case Report and Literature Review. Front Med (Lausanne) 2021; 8:755669. [PMID: 34869453 PMCID: PMC8636855 DOI: 10.3389/fmed.2021.755669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022] Open
Abstract
Gestational psittacosis and hemophagocytic syndrome (HPS) are rare clinical diseases. In this article, a case of gestational psittacosis concomitant with secondary HPS was reported. An analysis was performed on the clinical characteristics, signs, laboratory findings, progression, diagnosis, and treatment of a patient with gestational psittacosis concomitant with secondary HPS. Besides, the literature with respect to this disease was reviewed. This patient was definitively diagnosed through metagenomic next-generation sequencing techniques, bone marrow puncture and smear examination, and the determination of sCD25 level and natural killer (NK) cell activity. Anti-infectives such as doxycycline and etoposide combined with hormone chemotherapy achieved significant improvement in cough and expectoration, a return to normal temperature, and a significant improvement in oxygenation index. In addition, chest computed tomography revealed obvious absorption of lung lesions and a return of NK cell activity and sCD25 levels to normal ranges. Chlamydia psittaci pneumonia requires a clear determination of etiology, while HPS requires bone marrow puncture and smear examination, together with the determination of sCD25 level and NK cell activity in the blood. The findings of this study suggest that metagenomic next-generation sequencing is an effective instrument in clearly identifying pathogens that cause lung infection. Clinicians should consider atypical pathogens of lung infection in patients with poor response to empirical anti-infectives, and strive to design an effective treatment strategy as per an accurate diagnosis based on the etiology. As for patients suffering from long-term high fever and poor temperature control after broad-spectrum antibiotic treatment, non-infectious fever should be taken into account. A rapid and clear diagnosis would significantly improve patient prognosis.
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Affiliation(s)
- Li Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Pulin Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Bo Pang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Peipei Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ran Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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8
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Liver Biopsy in Pregnancy: Two Case Reports and Review of the Literature. Dig Dis Sci 2021; 66:4090-4098. [PMID: 33433812 DOI: 10.1007/s10620-020-06786-2] [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: 08/30/2020] [Accepted: 12/14/2020] [Indexed: 12/09/2022]
Abstract
The etiology of most cases of liver diseases in pregnancy can be diagnosed with a thorough history, physical examination, laboratory values, serology, and noninvasive imaging. However, atypical clinical and laboratory presentations of liver diseases/chemistries require a liver biopsy to render an accurate diagnosis in cases where the biopsy results affect the timing of delivery or impact choice of medical therapy. According to the American College of Gastroenterology, liver biopsy can be effectively and safely conducted in pregnant women. Conventional routes of performing a liver biopsy include the percutaneous, transjugular route, and surgical methods. Endoscopic ultrasound-guided liver biopsy is a recent technique that has not yet gained widespread adoption but can potentially serve as an alternative route for obtaining the liver sample. Adverse events associated with liver biopsy include abdominal pain and hemorrhage. Maternal and fetal outcomes are limited to increased risk of preterm birth and small for gestational age neonate. However, very few studies have formally evaluated the safety of liver biopsy in pregnant women. In this review, we present two successful cases of liver biopsy performed during pregnancy and summarize the most recent evidence regarding the safety and outcomes of the procedure in pregnancy to assist clinicians in their decision to perform a liver biopsy during pregnancy or postpone it until after delivery.
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9
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Takahashi M, Makino S, Iizuka H, Noguchi M, Yoshida K. Chronic active Epstein-Barr virus-associated secondary hemophagocytic lymphohistiocytosis in pregnancy: a case report. BMC Pregnancy Childbirth 2021; 21:681. [PMID: 34620104 PMCID: PMC8495184 DOI: 10.1186/s12884-021-04150-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare and fatal disease characterized by uncontrolled immune cell activation that can lead to a cytokine storm. Unfortunately, this condition can occur even during pregnancy, threatening both maternal and fetal lives. CASE PRESENTATION A 23-year-old nulliparous woman at 26 weeks of gestation presented with continuous fever, coughing, and sore throat. Upon arrival at our hospital, her temperature was >38°C and laboratory findings indicated cytopenia (neutrophil count, 779/μL; hemoglobin level, 10.2 g/dL; platelet count, 29,000/μL), elevated ferritin level (1,308 ng/mL), and elevated soluble interleukin-2 receptor level (11,200 U/mL). Computed tomography showed marked splenomegaly. Bone marrow examination revealed hemophagocytosis, and blood examination showed a plasma Epstein-Barr virus (EBV) DNA level of 8.9 × 105 copies/μg. The monoclonal proliferation of EBV-infected T cells was confirmed by Southern blotting, and the patient was diagnosed with chronic active EBV-associated sHLH and T-cell lymphoproliferative disease. Immediately after admission, the patient's condition suddenly deteriorated. She developed shock and disseminated intravascular coagulation, requiring endotracheal intubation along with methylprednisolone pulse and etoposide therapy. Although the patient recovered, she delivered a stillborn baby. After delivery, she was treated with reduced-dose dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC) and steroid (dexamethasone), methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) chemotherapies. Five months after diagnosis, she received human leukocyte antigen-haploidentical allogeneic bone marrow transplantation from her sister. She remains in remission for 5 months from the time of transplantation to the present. CONCLUSIONS sHLH, which may cause maternal and fetal death, should be carefully considered in critically ill pregnant women, particularly those presenting with continuous fever and cytopenia.
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Affiliation(s)
- Masaya Takahashi
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan.
| | - Hiroko Iizuka
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Koyo Yoshida
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
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10
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Aziz A, Castaneda EE, Ahmad N, Veerapalli H, Rockferry AG, Lankala CR, Hamid P. Exploring Macrophage Activation Syndrome Secondary to Systemic Lupus Erythematosus in Adults: A Systematic Review of the Literature. Cureus 2021; 13:e18822. [PMID: 34804679 PMCID: PMC8592789 DOI: 10.7759/cureus.18822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/16/2021] [Indexed: 02/06/2023] Open
Abstract
Among the autoimmune (AI) diseases, systemic lupus erythematosus (SLE) is known to mimic various disease processes and this can lead to under-diagnosis of macrophage activation syndrome (a dire complication). We aimed at performing a systematic review to identify trigger factors that could lead to the development of macrophage activation syndrome (MAS) in patients with SLE as well as identify factors that can affect mortality. We searched the following databases to extract relevant articles: PubMed, ScienceDirect, Cochrane library, Pro-Quest, and Google Scholar. We used search terms including but not limited to hemophagocytic syndromes OR hemophagocytic lymphohistiocytosis OR macrophage activation syndrome OR HLH OR secondary hemophagocytic lymphohistiocytosis AND systemic lupus erythematosus OR SLE. We screened the articles first by titles and abstracts and later by full text. After the application of our eligibility criteria, we identified eight studies to include in our final synthesis. The studies showed that lupus flare itself, as well as, time to onset and high systemic lupus erythematosus disease activity index (SLEDAI) scores, were major risk factors that led to the development of MAS. In addition, infections followed by drugs, underlying malignancy, and pregnancy were other potential trigger factors identified. Studies also detected that MAS development led to high intensive care unit (ICU) admissions and in-hospital mortalities with C-reactive protein (CRP) levels, age, presence of infection, leukopenia, thrombocytopenia, MAS throughout the hospital stay, and high liver function tests (LFTs) as signs of poor prognosis. Additionally, ferritin levels, LFTs, and triglyceride levels formed an important part of diagnostic criteria. However, our review was limited due to the absence of prospective studies and heterogeneity in the studies seen. More studies need to be done to identify various factors leading to hemophagocytic lymphohistiocytosis (HLH) in autoimmune diseases with validated criteria for MAS secondary to autoimmune diseases.
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Affiliation(s)
- Afia Aziz
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Everardo E Castaneda
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Noorain Ahmad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harish Veerapalli
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amy G Rockferry
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chetan Reddy Lankala
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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11
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Potts J, Gaudet B, Durie D, Quinones J. Haemophagocytic lymphohistiocytosis in pregnancy: a pertinent case during the COVID-19 pandemic. BMJ Case Rep 2021; 14:14/9/e244716. [PMID: 34535494 PMCID: PMC8451309 DOI: 10.1136/bcr-2021-244716] [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] [Indexed: 11/06/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare, often fatal disease, and presents a diagnostic challenge in the pregnant patient. This challenge is particularly relevant during the current COVID-19 pandemic. We present a case of HLH in a pregnant woman presenting with fever predating the COVID-19 pandemic. A 33-year-old, gravida 2, para 1 at 27 weeks’ gestation presented with fever, transaminitis, thrombocytopenia and elevated ferritin. After treatment according to the HLH-94 protocol, caesarean delivery and weeks of intensive care, the patient recovered fully. With prompt diagnosis and a multispecialty team at our tertiary care facility, she and her baby overcame a dire prognosis. HLH should be considered in pregnant patients presenting with a febrile illness. Particularly in cases of severe COVID-19, secondary HLH must be considered as an associated diagnosis.
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Affiliation(s)
- Jacqueline Potts
- Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | | | - Danielle Durie
- Maternal Fetal Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Joanne Quinones
- Maternal Fetal Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
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12
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Liu L, Cui Y, Zhou Q, Zhao H, Li X. Hemophagocytic lymphohistiocytosis during pregnancy: a review of the literature in epidemiology, pathogenesis, diagnosis and treatment. Orphanet J Rare Dis 2021; 16:281. [PMID: 34154616 PMCID: PMC8215746 DOI: 10.1186/s13023-021-01790-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/25/2021] [Indexed: 12/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis during pregnancy is rare; it is often misdiagnosed, resulting in a high maternal and foetal mortality rate. Herein, based on limited case reports including antepartum and postpartum cases, we reviewed the current studies of pregnancy-related hemophagocytic lymphohistiocytosis, and compared the epidemiology, aetiology, diagnosis and treatment of pregnancy-related hemophagocytic lymphohistiocytosis with non-pregnancy, enriching the understanding of hemophagocytic lymphohistiocytosis and its treatment in obstetrics.
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Affiliation(s)
- Lidong Liu
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China
| | - Yutong Cui
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China
| | - Qiongjie Zhou
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Huanqiang Zhao
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China
| | - Xiaotian Li
- Obstetrics and Gynecology Hospital of Fudan University, Fangxie Road 419, Huangpu District, Shanghai, 200011, China. .,The Institute of Biomedical Science, Fudan University, Shanghai, China. .,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China.
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13
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Adult-Onset Still's Disease Presenting as Macrophage-Activation Syndrome With Critical Illness in the Third Trimester of Pregnancy: A Case Report. Crit Care Explor 2021; 3:e0440. [PMID: 34046637 PMCID: PMC8148416 DOI: 10.1097/cce.0000000000000440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Supplemental Digital Content is available in the text. BACKGROUND: We report a case of a young woman with adult-onset Still’s disease presenting as macrophage-activation syndrome complicated by shock and respiratory failure during the third trimester of pregnancy. CASE SUMMARY: A previously healthy 26-year-old woman at 35 weeks of gestation presented with 1 week of constitutional symptoms and was found to be febrile, tachycardic, and hypotensive. She delivered a healthy neonate by cesarean section. Following delivery, she had worsening hypotension and fevers despite fluid resuscitation and antibiotics, and developed progressive hypoxemia requiring up to 60% Fio2, with bilateral upper-lobe predominant opacities on chest CT. She also had laboratory derangements including anemia, thrombocytopenia, low fibrinogen, elevated ferritin, and abnormal liver chemistries. After extensive testing to exclude infections, hemolysis, and other pertinent disorders, the development of polyarthralgias and a characteristic rash fulfilled criteria for adult-onset Still’s disease complicated by macrophage-activation syndrome. Her condition improved with immunosuppressive therapy. CONCLUSION: To our knowledge, this is the first report of new-onset adult-onset Still’s disease during the third trimester of pregnancy, which presented as macrophage-activation syndrome. In the context of late pregnancy, macrophage-activation syndrome can mimic or raise concern for hemolysis, elevated liver enzymes, and low platelet syndrome and other peripartum disorders. Furthermore, the characteristic articular symptoms of adult-onset Still’s disease may be mild and/or delayed, and pulmonary involvement with severe hypoxemia can occur. Clinicians should consider this diagnosis when evaluating a pregnant patient with unexplained fever and multiorgan dysfunction.
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