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Jevtic D, da Silva MD, Haylock AB, Nordstrom CW, Oluic S, Pantic N, Nikolajevic M, Nikolajevic N, Kotseva M, Dumic I. Hemophagocytic Lymphohistiocytosis (HLH) in Patients with Tick-Borne Illness: A Scoping Review of 98 Cases. Infect Dis Rep 2024; 16:154-169. [PMID: 38525759 PMCID: PMC10961790 DOI: 10.3390/idr16020012] [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: 12/13/2023] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) secondary to tick-borne infections is a rare but potentially life-threatening syndrome. We performed a scoping review according to PRISMA guidelines to systematically analyze the existing literature on the topic. A total of 98 patients were included, with a mean age of 43.7 years, of which 64% were men. Most cases, 31%, were reported from the USA. Immunosuppression was present in 21.4%, with the most common cause being previous solid organ transplantation. Constitutional symptoms were the most common, observed in 83.7% of the patients, while fever was reported in 70.4% of cases. Sepsis was present in 27.6%. The most common laboratory abnormalities in this cohort were thrombocytopenia in 81.6% of patients, while anemia, leukopenia, and leukocytosis were observed in 75.5%, 55.1%, and 10.2%, respectively. Liver enzyme elevation was noted in 63.3% of cases. The H-score was analyzed in 64 patients, with the mean value being 209, and bone marrow analysis was performed in 61.2% of patients. Ehrlichia spp. was the main isolated agent associated with HLH in 45.9%, followed by Rickettsia spp. in 14.3% and Anaplasma phagocytophilum in 12.2%. Notably, no patient with Powassan virus infection or Lyme borreliosis developed HLH. The most common complications were acute kidney injury (AKI) in 35.7% of patients, shock with multiple organ dysfunction in 22.5%, encephalopathy/seizure in 20.4%, respiratory failure in 16.3%, and cardiac complications in 7.1% of patients. Treatment included antibiotic therapy alone in 43.9%, while 5.1% of patients were treated with immunosuppressants alone. Treatment with both antibiotics and immunosuppressants was used in 51% of patients. Appropriate empiric antibiotics were used in 62.2%. In 43.9% of cases of HLH due to tick-borne disease, patients received only antimicrobial therapy, and 88.4% of those recovered completely without the need for immunosuppressive therapy. The mortality rate in our review was 16.3%, and patients who received inappropriate or delayed empiric therapy had a worse outcome. Hence, we suggest empiric antibiotic treatment in patients who are suspected of having HLH due to tick-borne disease or in whom diagnostic uncertainty persists due to diagnostic delay in order to minimize mortality.
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Affiliation(s)
- Dorde Jevtic
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.J.); (A.B.H.)
- Department of Medicine, NYC Health + Hospitals/Elmhurst, New York, NY 11373, USA
| | | | - Alberto Busmail Haylock
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.J.); (A.B.H.)
- Department of Medicine, NYC Health + Hospitals/Elmhurst, New York, NY 11373, USA
| | - Charles W. Nordstrom
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA;
- Mayo Clinic College of Medicine and Science, Rochester, MN 55902, USA
| | - Stevan Oluic
- Department of Internal Medicine, Mayo Clinic Health System, Mankato, MN 56001, USA;
| | - Nikola Pantic
- Clinic of Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Milan Nikolajevic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.N.); (N.N.)
| | - Nikola Nikolajevic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.N.); (N.N.)
| | - Magdalena Kotseva
- Internal Medicine Residency, Franciscan Health, Olympia Fields, Chicago, IL 60461, USA;
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA;
- Mayo Clinic College of Medicine and Science, Rochester, MN 55902, USA
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Gabela Sanchez MA, Nagarajan V, Shenoi A. Fever, Rash, Cytopenia, and Disseminated Intravascular Coagulation in a 6-year-old. Pediatr Rev 2022; 43:171-173. [PMID: 35229107 DOI: 10.1542/pir.2020-002782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Asha Shenoi
- Department of Pediatrics, University of Kentucky, Lexington, KY
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Singh NS, Pagano AL, Hays AJ, Kats A, Dahl SM, Warady BA, Beins NT, Yin DE. Ehrlichia-induced hemophagocytic lymphohistiocytosis in a pediatric kidney transplant recipient. Pediatr Transplant 2022; 26:e14134. [PMID: 34595809 DOI: 10.1111/petr.14134] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/03/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Kidney transplant patients are susceptible to a variety of infections in the post-transplant period due to the use of immunosuppressant medications. Ehrlichiosis is a rare infection in solid organ transplant recipients with signs and symptoms that mimic rejection and other viral infections. Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyperinflammatory syndrome that can be triggered by infections. METHODS We describe a pediatric kidney transplant recipient who experienced secondary HLH due to ehrlichiosis within the initial post-transplant month. RESULT Our patient improved after treatment with doxycycline, corticosteroids, and intravenous immunoglobulin (IVIG). CONCLUSION Clinicians should consider infections such as ehrlichiosis as a potential cause of illness in febrile solid organ transplant recipients in immediate post-transplant period, especially when accompanied by a compatible exposure history.
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Affiliation(s)
- Nisha S Singh
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Alexa L Pagano
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Kansas, USA
| | - Allyson J Hays
- Department of Pediatric Hematology and Oncology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Alexander Kats
- Division of Pathology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Steven M Dahl
- Divisions of Infectious Diseases and Clinical Pharmacology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Nathan T Beins
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Dwight E Yin
- Divisions of Infectious Diseases and Clinical Pharmacology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
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Cabler SS, Hogan PG, Fritz SA, Bednarski JJ, Hunstad DA. Incidence and treatment of hemophagocytic lymphohistiocytosis in hospitalized children with Ehrlichia infection. Pediatr Blood Cancer 2020; 67:e28436. [PMID: 32706439 DOI: 10.1002/pbc.28436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/23/2022]
Abstract
We report a large cohort of pediatric patients with human monocytic ehrlichiosis (HME), enabling an estimated incidence of secondary hemophagocytic lymphohistiocytosis (HLH) in hospitalized children with HME. Among 49 children with PCR-confirmed Ehrlichia infection, 8 (16%) met current criteria for HLH. Those with HLH had more significant hematologic abnormalities and longer durations from symptom onset to admission and definitive anti-infective therapy. Among these eight, three received chemotherapy plus doxycycline, one of whom died; the other five were treated with doxycycline without chemotherapy, and all survived without HLH recurrence. Our findings demonstrate that antimicrobial therapy alone can successfully resolve Ehrlichia-associated HLH.
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Affiliation(s)
- Stephanie S Cabler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick G Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie A Fritz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey J Bednarski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - David A Hunstad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
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Agudelo Higuita NI, Yuen C. Hemophagocytic Lymphohistiocytosis Secondary to Ehrlichia Chaffeensis in Adults: A Case Series From Oklahoma. Am J Med Sci 2020; 361:269-273. [PMID: 32928497 DOI: 10.1016/j.amjms.2020.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation that occurs as either a familial disorder or as a sporadic condition in association with a variety of triggers. Infections are the most common cause of HLH in adults and should be searched for as early treatment usually results in a favorable outcome. Human monocytotropic ehrlichiosis (HME) is a very rare cause of HLH. Failure to consider ehrlichiosis can result in misdiagnosis and an increased length of hospitalization and healthcare cost as described in our report. Treatment for secondary HLH is aimed at reducing hypercytokinemia and eradicating inflammatory and infected cells. It is important to promptly initiate doxycycline when tick-borne diseases are being entertained as a possible trigger, as the antibiotic is effective, safe and inexpensive.
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Affiliation(s)
- Nelson Iván Agudelo Higuita
- Section of Infectious Diseases, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Carrie Yuen
- Section of Hematology and Oncology, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Affiliation(s)
- Jennifer S Read
- Department of Pediatrics, University of Vermont Medical Center, Burlington, VT.,Infectious Disease Epidemiology, Vermont Department of Health, Burlington, VT
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Otrock ZK, Eby CS, Burnham CAD. Human ehrlichiosis at a tertiary-care academic medical center: Clinical associations and outcomes of transplant patients and patients with hemophagocytic lymphohistiocytosis. Blood Cells Mol Dis 2019; 77:17-22. [PMID: 30913447 DOI: 10.1016/j.bcmd.2019.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ehrlichiosis is an acute febrile tick-borne disease which can rarely be a trigger for secondary hemophagocytic lymphohistiocytosis (HLH). METHODS We reviewed our experience with Ehrlichia infections at a tertiary-care academic medical center. RESULTS Over 10 years, 157 cases of ehrlichiosis were identified. Ten patients (6.4%) had infection with E. ewingii, 7(4.5%) of whom were transplant patients as compared to 3(1.9%) non-transplant patients (p = .035). Transplant patients were more likely to have leukopenia and elevated creatinine compared to immunocompetent patients; length of hospital stay and early mortality were not different between the two groups. Ten patients met the HLH-2004 diagnosis criteria, which could be an underestimation of HLH occurrence as most patients were not completely evaluated for these criteria. We calculated the H-Score to find the probability of HLH; 25 patients scored high making the occurrence rate of HLH at least 16%. Ehrlichia-induced HLH patients (N = 25) had more anemia, thrombocytopenia, elevated creatinine and AST. Moreover, they had a significantly longer hospital stay (median 9 days) compared to patients without HLH (median 4 days) (p = .006). CONCLUSIONS Ehrlichia-induced HLH is a potential serious complication with relatively high occurrence rate; patients manifest severe disease with end-organ damage requiring longer hospital stay.
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Affiliation(s)
- Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA.
| | - Charles S Eby
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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A Fatal Case of Hemophagocytic Lymphohistiocytosis in a Patient With Ehrlichiosis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheng A, Williams F, Fortenberry J, Preissig C, Salinas S, Kamat P. Use of Extracorporeal Support in Hemophagocytic Lymphohistiocytosis Secondary to Ehrlichiosis. Pediatrics 2016; 138:peds.2015-4176. [PMID: 27633921 DOI: 10.1542/peds.2015-4176] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2016] [Indexed: 11/24/2022] Open
Abstract
Ehrlichiosis, caused by transmission of Ehrlichia chaffeensis to humans through the bite of an infected lone star tick, can lead to secondary hemophagocytic lymphohistiocytosis (HLH), a life-threatening condition caused by uncontrolled activation of the cellular immune system. We describe a child with HLH secondary to ehrlichiosis who developed multiorgan failure and was successfully managed with extracorporeal membrane oxygenation (ECMO). A 9-year-old boy developed headaches, fever, and sore throat after suspected tick exposure. He presented with pancytopenia, elevated ferritin, and soluble interleukin-2 receptor levels, all consistent with HLH. Bone marrow biopsy revealed hemophagocytosis. Polymerase chain reaction was positive for E chaffeensis He developed acute kidney injury, coagulation failure, hepatic insufficiency, and progressive respiratory failure requiring intubation. Due to refractory hypoxemia, he was cannulated for veno-venous ECMO. Continuous veno-venous hemofiltration was used to manage acute kidney injury and fluid overload. He received doxycycline and dexamethasone/etoposide for treatment of ehrlichiosis and HLH, respectively. Plasma exchange was used for thrombocytopenia-associated multiple organ failure. The patient was decannulated after 140 hours of ECMO and subsequently transferred for inpatient rehabilitation after extubation. Review of the Extracorporeal Life Support Organization Registry database identified 6 patients with tickborne diseases who received ECMO for organ support (survival in 3 of 6); ehrlichiosis was not reported in any of these cases. ECMO likely allowed a platform for stabilization and additional therapeutic interventions in this patient.
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Affiliation(s)
- Amy Cheng
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia;
| | - Feifei Williams
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Department of Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - James Fortenberry
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Department of Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Catherine Preissig
- Department of Critical Care Medicine, Children's Hospital Navicent Health, Macon, Georgia; and
| | | | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Department of Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
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Biggs HM, Behravesh CB, Bradley KK, Dahlgren FS, Drexler NA, Dumler JS, Folk SM, Kato CY, Lash RR, Levin ML, Massung RF, Nadelman RB, Nicholson WL, Paddock CD, Pritt BS, Traeger MS. Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States. MMWR Recomm Rep 2016; 65:1-44. [PMID: 27172113 DOI: 10.15585/mmwr.rr6502a1] [Citation(s) in RCA: 303] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.
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Affiliation(s)
- Holly M Biggs
- National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
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Otrock ZK, Gonzalez MD, Eby CS. Ehrlichia-Induced Hemophagocytic Lymphohistiocytosis: A Case Series and Review of Literature. Blood Cells Mol Dis 2015; 55:191-3. [DOI: 10.1016/j.bcmd.2015.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
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