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Cazzaniga J, Georgiyeva K, Siguenza A, Gonzalez T, Ferraro P. Using Diagnostic Radiological Imaging Modalities to Explore Neurological Dysfunction and Renal Failure in the Intersection of Hemophagocytic Lymphohistiocytosis, Macrophage Activation Syndrome, and Lupus. Cureus 2024; 16:e54005. [PMID: 38496127 PMCID: PMC10944546 DOI: 10.7759/cureus.54005] [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: 12/11/2023] [Accepted: 02/11/2024] [Indexed: 03/19/2024] Open
Abstract
This comprehensive case report and literature review explore the intricate intersection of hemophagocytic lymphohistiocytosis (HLH), macrophage activation syndrome (MAS), and systemic lupus erythematosus (SLE) in a 39-year-old patient, emphasizing the challenging diagnostic and therapeutic landscape. The patient's journey includes neurological dysfunction, renal failure, and clinical complexities, showcasing the rarity of these overlapping conditions. The report explains the diagnostic process, clinical and laboratory findings, specialty consultations, and treatment decisions leading to the diagnosis of SLE with features of MAS overlapping with HLH. By offering insights into the latest research and clinical perspectives, this case report contributes to a deeper understanding of these disorders, aiming to guide clinicians in recognizing and managing such intricate cases effectively.
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Affiliation(s)
- Juliana Cazzaniga
- Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | | | | | | | - Pablo Ferraro
- Hematology and Oncology, Memorial Healthcare System, Pembroke Pines, USA
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2
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Noboa MER, Lopez-Arevalo H, Patel AR, Arora S, Manadan AM. Nationwide analysis of adult hospitalizations with hemophagocytic lymphohistiocytosis and systemic lupus erythematosus. Clin Rheumatol 2023:10.1007/s10067-023-06594-9. [PMID: 37081184 DOI: 10.1007/s10067-023-06594-9] [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: 10/02/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a well-recognized complication of systemic lupus erythematosus (SLE). This study aims to characterize HLH with and without SLE in the US adult inpatient population. METHODS We performed a retrospective study of HLH with and without SLE from the 2016-2019 National Inpatient Sample (NIS) database. We described the demographic characteristics of HLH with and without SLE. Multivariable analysis was performed to calculate odds ratios (OR) for in-hospital death. RESULTS A total of 8690 hospitalizations had HLH. Of those 605 (7%) had SLE, and 8085 (93%) did not have SLE. Relative to the non-SLE group, the SLE group was younger, had more females, less whites, more African Americans, more Hispanics, and more Asian/Pacific Islanders. Over 60% of HLH with or without SLE had a concurrent infection. Sixty (9.9%) of HLH hospitalizations with SLE died compared to 1735 (21.5%) of those without SLE. Among HLH hospitalizations, multivariable analysis showed that age (OR 1.02; 95% C.I. 1.016-1.031), Charlson Comorbidity Index (OR 1.15; 95% C.I. 1.091-1.213), infections (OR 3.35; 95% C.I. 2.467-4.557), and leukemia/lymphoma (OR 1.46; 95% C.I. 1.112-1.905) had higher odds of in-hospital death. SLE did not increase the odds of death. CONCLUSIONS Inpatients with both HLH and SLE were younger, had a higher proportion of racial/ethnic minorities, and were predominately female. One out of every 10 hospitalizations for HLH ended in death but SLE itself was not an independent risk factor for death. Concurrent infection was the variable most associated with HLH death. Key Points • HLH and SLE group were younger and had higher proportions of female and racial/ethnic minorities. • SLE was not an independent risk factor for death in HLH patients.
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Affiliation(s)
| | - Hugo Lopez-Arevalo
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Axi R Patel
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Shilpa Arora
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
| | - Augustine M Manadan
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
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Peng LY, Liu JB, Zuo HJ, Shen GF. Unusual presentation of systemic lupus erythematosus as hemophagocytic lymphohistiocytosis in a female patient: A case report. World J Clin Cases 2023; 11:909-917. [PMID: 36818616 PMCID: PMC9928712 DOI: 10.12998/wjcc.v11.i4.909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disorder, often resulting in the immune-mediated injury of multiple organ systems, including primary HLH and secondary HLH (sHLH). Among them, sHLH results from infections, malignant, or autoimmune conditions, which have quite poor outcomes even with aggressive management and are more common in adults.
CASE SUMMARY We report a rare case of a 36-year-old female manifested with sHLH on background with systemic lupus erythematosus (SLE). During hospitalization, the patient was characterized by recurrent high-grade fever, petechiae and ecchymoses of abdominal skin, and pulmonary infection. Whole exon gene sequencing revealed decreased activity of natural killer cells. She received systematic treatment with Methylprednisolone, Etoposide, and anti-infective drugs. Intravenous immunoglobulin and plasmapheresis were applied when the condition was extremely acute and progressive. The patient recovered and did not present any relapse of the HLH for one year of follow-up.
CONCLUSION The case showed sHLH, thrombotic microvascular, and infection in the whole course of the disease, which was rarely reported by now. The treatment of the patient emphasizes that early recognition and treatment of sHLH in SLE patients was of utmost importance to improve the prognosis and survival rate of patients.
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Affiliation(s)
- Li-Yuan Peng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Jing-Bo Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hou-Juan Zuo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Gui-Fen Shen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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Ginikopoulou E. Plasma exchange and COVID 19. Transfus Apher Sci 2022; 61:103598. [DOI: 10.1016/j.transci.2022.103598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chen Y, Hu Z, Cai S, Shen G, Zhong J, Dong L. Efficacy of plasma exchange on top of standard immunosuppressive therapy in adult autoimmune inflammatory rheumatic diseases-associated macrophage activation syndrome, a single center real-world analysis. Semin Arthritis Rheum 2022; 55:152043. [DOI: 10.1016/j.semarthrit.2022.152043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 10/18/2022]
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Ding Y, Ge Y. Anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis complicated with macrophage activation syndrome. Ther Adv Chronic Dis 2022; 13:20406223221098128. [PMID: 35586303 PMCID: PMC9109495 DOI: 10.1177/20406223221098128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/13/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody-positive
dermatomyositis (DM) has low survival rate, whereas macrophage activation
syndrome (MAS) is a severe and life-threatening syndrome associated with
autoimmune diseases. Their coexistence is very rare. This study aimed to
describe the prevalence, clinical characteristics, and outcomes of anti-MDA5
antibodies-positive DM patients complicated with MAS. Methods: In this retrospective study, we enrolled DM patients with anti-MDA5
antibodies, who were hospitalized between 2016 and 2020 and included
patients diagnosed with MAS. Results: We identified four (2%) DM patients with anti-MDA5 antibodies. They were
females with interstitial lung disease (ILD). The level of aspartate
aminotransferase (AST), lactate dehydrogenase (LDH), and ferritin were
significantly higher in the MAS group than those without MAS
(p < 0.05). Patients with MAS were significantly
more likely to develop a dysphagia (p = 0.012). Literature
review revealed eight similar cases. Together with the present study, we
identified 12 patients complicated with ILD. The median age of disease onset
was 52 years with a male to female ratio of 1:6. The median duration between
DM onset and MAS diagnosis was 3 months. The mortality of MAS in anti-MDA5
antibody-positive DM was 50%. Patients who died were older than those who
survived (56.7 years versus 35.5 years;
p = 0.015). Conclusions: MAS was rare in anti-MDA5 antibody-positive DM. The higher the level of AST,
LDH, and ferritin, the greater the risk of MAS. They were associated with
high mortality rates, particularly in older patients.
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Affiliation(s)
- Yukang Ding
- Department of Rheumatology, The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029 Beijing, China
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Cytokine Storm in COVID-19: Immunopathogenesis and Therapy. Medicina (B Aires) 2022; 58:medicina58020144. [PMID: 35208467 PMCID: PMC8876409 DOI: 10.3390/medicina58020144] [Citation(s) in RCA: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/07/2022] [Accepted: 01/15/2022] [Indexed: 12/15/2022] Open
Abstract
A cytokine storm is a hyperinflammatory state secondary to the excessive production of cytokines by a deregulated immune system. It manifests clinically as an influenza-like syndrome, which can be complicated by multi-organ failure and coagulopathy, leading, in the most severe cases, even to death. The term cytokine storm was first used in 1993 to describe the graft-versus-host disease following allogeneic hematopoietic stem cell transplantation. It was then reused to define the adverse syndromes secondary to the administration of immunostimulating agents, such as anti-CD28 antibodies or bioengineered immune cells, i.e., CAR T-cell therapy. Currently, the concept of cytokine storm has been better elucidated and extended to the pathogenesis of many other conditions, such as sepsis, autoinflammatory disease, primary and secondary hemophagocytic lymphohistiocytosis, and multicentric Castleman disease. Moreover, cytokine storm has recently emerged as a key aspect in the novel Coronavirus disease 2019, as affected patients show high levels of several key pro-inflammatory cytokines, such as IL-1, IL-2, IL-6, TNF-α, IFN-γ, IP-10, GM-CSF, MCP-1, and IL-10, some of which also correlate with disease severity. Therefore, since the onset of the pandemic, numerous agents have been tested in the effort to mitigate the cytokine storm in COVID-19 patients, some of which are effective in reducing mortality, especially in critically ill patients, and are now becoming standards of care, such as glucocorticoids or some cytokine inhibitors. However, the challenge is still far from being met, and other therapeutic strategies are being tested in the hope that we can eventually overcome the disease.
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Maruyama A, Kokuzawa A, Yamauchi Y, Kirino Y, Nagai H, Inoue Y, Ota T, Chifu Y, Inokuchi S, Mitoma H, Akahoshi M, Sakai M, Ohta A, Iwamoto M, Tada Y. Usefulness of the severity classification for predicting drug-free remission in Japanese patients with adult-onset Still's disease. Mod Rheumatol 2021; 32:953-959. [PMID: 34918141 DOI: 10.1093/mr/roab083] [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: 06/09/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To investigate the usefulness of severity classification for predicting outcomes in patients with adult-onset Still's disease (AOSD). METHODS This was a multi-centre retrospective cohort study. AOSD patients were classified into mild, moderate, and severe groups based on severity classification (Japanese Ministry of Health, Labour and Welfare) during the initial treatment, and clinical features were compared among these groups. The primary endpoints were the AOSD-related mortality and drug-free remission rate. For comparison, the same analysis was performed in parallel for patient groups stratified by the modified Pouchot systemic score. RESULTS According to severity classification, 49 (35%), 37 (26%), and 56 patients (39%) were classified into mild, moderate, and severe groups, respectively. Patients in the severe group showed higher frequency of severe complications and the use of biological agents. Although AOSD-related survival was not significantly different (p = .0776), four of the five fatal cases were classified into the severe group. The severe group showed a reduced rate of drug-free remission (p = .0125). Patient groups classified by systemic score did not correlate with survival or drug-free remission. CONCLUSIONS Severity classification is useful for predicting outcomes in patients with AOSD.
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Affiliation(s)
- Akihito Maruyama
- Department of Rheumatology, Faculty of Medicine, Saga University, Saga, Japan
| | - Ayako Kokuzawa
- Department of Rheumatology and Clinical Immunology, Jichi Medical University, Shimotsuke, Japan
| | - Yusuke Yamauchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideto Nagai
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yasushi Inoue
- Division of Rheumatology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Toshiyuki Ota
- Center for Rheumatic Diseases, Iizuka Hospital, Iizuka, Japan
| | - Yutaka Chifu
- Division of Internal Medicine, Saiseikai Karatsu Hospital, Karatsu, Japan
| | - Satomi Inokuchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Rheumatology, Faculty of Medicine, Saga University, Saga, Japan
| | - Mariko Sakai
- Department of Rheumatology, Faculty of Medicine, Saga University, Saga, Japan
| | - Akihide Ohta
- Suigo-en Kohokai Group Medical Corporation, Fukuoka, Japan
| | - Masahiro Iwamoto
- Department of Rheumatology and Clinical Immunology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshifumi Tada
- Department of Rheumatology, Faculty of Medicine, Saga University, Saga, Japan.,Suigo-en Kohokai Group Medical Corporation, Fukuoka, Japan
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Mok CC, Hamijoyo L, Kasitanon N, Chen DY, Chen S, Yamaoka K, Oku K, Li MT, Zamora L, Bae SC, Navarra S, Morand EF, Tanaka Y. The Asia-Pacific League of Associations for Rheumatology consensus statements on the management of systemic lupus erythematosus. THE LANCET. RHEUMATOLOGY 2021; 3:e517-e531. [PMID: 38279404 DOI: 10.1016/s2665-9913(21)00009-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is prevalent in Asia and carries a variable prognosis among patients across the Asia-Pacific region, which could relate to access to health care, tolerability of medications, and adherence to therapies. Because many aspects of SLE are unique among patients from this region, the Asia-Pacific League of Associations for Rheumatology developed the first set of consensus recommendations on the management of SLE. A core panel of 13 rheumatologists drafted a set of statements through face-to-face meeting and teleconferences. A literature review was done for each statement to grade the quality of evidence and strength of recommendation. 29 independent specialists and three patients with SLE were then recruited for a modified Delphi process to establish consensus on the statements through an online voting platform. A total of 34 consensus recommendations were developed. Panellists agreed that patients with SLE should be referred to a specialist for the formulation of a treatment plan through shared decision making between patients and physicians. Remission was agreed to be the goal of therapy, but when it cannot be achieved, a low disease activity state should be aimed for. Patients should be screened for renal disease, and hydroxychloroquine is recommended for all Asian people with SLE. Major organ manifestations of SLE should be treated with induction immunosuppression and subsequently maintenance; options include cyclophosphamide, mycophenolate mofetil, azathioprine, and calcineurin inhibitors, in combination with glucocorticoids. Biologics, combination regimens, plasma exchange, and intravenous immunoglobulins should be reserved for cases of refractory or life-threatening disease. Anticoagulation therapy with warfarin is preferred to the direct oral anticoagulants for thromboembolic SLE manifestations associated with a high-risk antiphospholipid antibody profile.
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Affiliation(s)
- Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong Special Administrative Region, China.
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Jawa Barat, Indonesia
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Thailand
| | - Der Yuan Chen
- Rheumatology and Immunology Centre, China Medical University, Taichung, Taiwan
| | - Sheng Chen
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China; Chinese Academy of Medical Science, National Clinical Research Centre for Dermatological and Immunological Diseases, Beijing, China
| | - Leonid Zamora
- Section of Rheumatology, University of Santo Tomas, Manila, Philippines
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas, Manila, Philippines
| | - Eric F Morand
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, Australia
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Saleh R, Rahimi H, Dehghan A, Sadeghizadeh A, Gheisari A, Saeidi S, Pourmoghaddas Z. Successful treatment of plasmapheresis followed by interferon beta-1a in a child with severe COVID-19. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:30. [PMID: 34345241 PMCID: PMC8305773 DOI: 10.4103/jrms.jrms_756_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/13/2020] [Accepted: 12/22/2020] [Indexed: 11/04/2022]
Abstract
COVID-19 outbreak has become a global health concern due to challenges in treatment and high mortality rate; therefore, its therapeutic approaches play an important role in reducing the mortality rate and resolving this concern. Different therapies have been introduced, including interferon beta-1a and purification methods, for instance, plasmapheresis. In this article, we reported a child with severe COVID-19 who fully recovered after receiving plasmapheresis and interferon beta-1a.
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Affiliation(s)
- Rana Saleh
- Department of Pediatric Infectious Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Rahimi
- Department of Pediatric Infectious Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amin Dehghan
- Student Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atefeh Sadeghizadeh
- Department of Pediatric Intensive Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alaleh Gheisari
- Department of Pediatric Nephrology Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shima Saeidi
- Department of Pediatric Infectious Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Pourmoghaddas
- Department of Pediatric Infectious Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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Yildiz H, Bailly S, Van Den Neste E, Yombi JC. Clinical Management of Relapsed/Refractory Hemophagocytic Lymphohistiocytosis in Adult Patients: A Review of Current Strategies and Emerging Therapies. Ther Clin Risk Manag 2021; 17:293-304. [PMID: 33888986 PMCID: PMC8056168 DOI: 10.2147/tcrm.s195538] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is a severe disorder with high mortality. The aim of this review is to update clinical management of relapsed/refractory HLH in adults, with a focus on current and new therapies. Methods We searched relevant articles in Embase and PUBMED with the MESH term “hemophagocytic lymphohistiocytosis; refractory; relapsing; adult.” Results One hundred eight papers were found; of these, 22 were retained for this review. The treatment of HLH in adult is based on the HLH-94 regimen. The response rate is lower than in pediatric patients, and 20–30% are refractory to this therapy. DEP regimen and allogenic hematopoietic stem cell transplantation (HSCT) are associated with complete response and partial response in 27% and 49.2%, respectively. However, many patients fail to achieve a stable condition before HSCT, and mortality is higher in them. New drugs have been developed, such as emapalumab, ruxolitinib, and alemtuzumab, and they may be used as bridges to the curative HSCT. They are relatively well tolerated and have few or mild side effects. With these agents, the rate of partial response ranges from 14.2% to 100%, while the rate of complete response is highly variable according to study and medication used. The number of patients who achieved HSCT ranged from 44.8% to 77%, with a survival rate of 55.9% to 100%. However, the populations in these studies are mainly composed of mixed-age patients (pediatric and adult patients), and studies including only adult patients are scarce. Conclusion Relapsed or refractory HLH in adult patients is associated with poor outcome, and consolidation with HSCT may be required in some cases. Mortality related to HSCT is mainly due to active HLH disease before HSCT and post HSCT complications. New drugs, such as empalumab, ruxolitinib, and alemtuzumab are interesting since these agents may be used as bridges to HSCT with increases in the numbers of patients proceeding to HSCT and survival rate.
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Affiliation(s)
- Halil Yildiz
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Sarah Bailly
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Eric Van Den Neste
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Jean Cyr Yombi
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
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12
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Kim JS, Lee JY, Yang JW, Lee KH, Effenberger M, Szpirt W, Kronbichler A, Shin JI. Immunopathogenesis and treatment of cytokine storm in COVID-19. Theranostics 2021; 11:316-329. [PMID: 33391477 PMCID: PMC7681075 DOI: 10.7150/thno.49713] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/20/2020] [Indexed: 12/18/2022] Open
Abstract
Severe coronavirus disease 2019 (COVID-19) is characterized by systemic hyper-inflammation, acute respiratory distress syndrome, and multiple organ failure. Cytokine storm refers to a set of clinical conditions caused by excessive immune reactions and has been recognized as a leading cause of severe COVID-19. While comparisons have been made between COVID-19 cytokine storm and other kinds of cytokine storm such as hemophagocytic lymphohistiocytosis and cytokine release syndrome, the pathogenesis of cytokine storm has not been clearly elucidated yet. Recent studies have shown that impaired response of type-1 IFNs in early stage of COVID-19 infection played a major role in the development of cytokine storm, and various cytokines such as IL-6 and IL-1 were involved in severe COVID-19. Furthermore, many clinical evidences have indicated the importance of anti-inflammatory therapy in severe COVID-19. Several approaches are currently being used to treat the observed cytokine storm associated with COVID-19, and expectations are especially high for new cytokine-targeted therapies, such as tocilizumab, anakinra, and baricitinib. Although a number of studies have been conducted on anti-inflammatory treatments for severe COVID-19, no specific recommendations have been made on which drugs should be used for which patients and when. In this review, we provide an overview of cytokine storm in COVID-19 and treatments currently being used to address it. In addition, we discuss the potential therapeutic role of extracorporeal cytokine removal to treat the cytokine storm associated with COVID-19.
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Affiliation(s)
- Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Maria Effenberger
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University Innsbruck, Innsbruck, Austria
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
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Gabr JB, Liu E, Mian S, Pillittere J, Bonilla E, Banki K, Perl A. Successful treatment of secondary macrophage activation syndrome with emapalumab in a patient with newly diagnosed adult-onset Still's disease: case report and review of the literature. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:887. [PMID: 32793731 DOI: 10.21037/atm-20-3127] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Here, we present a 22-year-old female patient with adult-onset Still's disease (AOSD) who was newly diagnosed in the setting of secondary macrophage activation syndrome (MAS), a rare, life-threatening inflammatory disease with 50% mortality due to multi-organ failure. She met the diagnostic criteria of AOSD and MAS, while genetic testing excluded primary causes of MAS. She had high fevers, anemia, thrombocytopenia, splenomegaly, hematophagocytosis, and elevated serum ferritin (37,950 ng/mL) and CD25 levels (11,870 pg/mL), which remained unresponsive to corticosteroids and anakinra. Her serum interferon gamma (IFN-γ) levels were elevated (7 pg/mL). She was markedly responsive to IFN-γ blockade with emapalumab that eliminated her fevers and all MAS-associated laboratory abnormalities. This report provides initial evidence for therapeutic efficacy for IFN-γ blockade in AOSD and secondary MAS.
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Affiliation(s)
- Jihad Ben Gabr
- Department of Medicine, Upstate Medical University, College of Medicine, Syracuse, NY, USA
| | - Eric Liu
- Department of Medicine, Upstate Medical University, College of Medicine, Syracuse, NY, USA
| | - Sundus Mian
- Department of Medicine, Upstate Medical University, College of Medicine, Syracuse, NY, USA
| | - Julie Pillittere
- Department of Medicine, Upstate Medical University, College of Medicine, Syracuse, NY, USA
| | - Eduardo Bonilla
- Department of Medicine, Upstate Medical University, College of Medicine, Syracuse, NY, USA
| | - Katalin Banki
- Department of Pathology, State University of New York, College of Medicine, Syracuse, NY, USA
| | - Andras Perl
- Department of Medicine, Upstate Medical University, College of Medicine, Syracuse, NY, USA.,Department of Microbiology and Immunology, Upstate Medical University, College of Medicine, Syracuse, NY, USA.,Department of Biochemistry and Molecular Biology, Upstate Medical University, College of Medicine, Syracuse, NY, USA
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14
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Liu B, Li M, Zhou Z, Guan X, Xiang Y. Can we use interleukin-6 (IL-6) blockade for coronavirus disease 2019 (COVID-19)-induced cytokine release syndrome (CRS)? J Autoimmun 2020; 111:102452. [PMID: 32291137 PMCID: PMC7151347 DOI: 10.1016/j.jaut.2020.102452] [Citation(s) in RCA: 499] [Impact Index Per Article: 124.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
The emergent outbreak of coronavirus disease 2019 (COVID-19) has caused a global pandemic. Acute respiratory distress syndrome (ARDS) and multiorgan dysfunction are among the leading causes of death in critically ill patients with COVID-19. The elevated inflammatory cytokines suggest that a cytokine storm, also known as cytokine release syndrome (CRS), may play a major role in the pathology of COVID-19. However, the efficacy of corticosteroids, commonly utilized antiinflammatory agents, to treat COVID-19-induced CRS is controversial. There is an urgent need for novel therapies to treat COVID-19-induced CRS. Here, we discuss the pathogenesis of severe acute respiratory syndrome (SARS)-induced CRS, compare the CRS in COVID-19 with that in SARS and Middle East respiratory syndrome (MERS), and summarize the existing therapies for CRS. We propose to utilize interleukin-6 (IL-6) blockade to manage COVID-19-induced CRS and discuss several factors that should be taken into consideration for its clinical application.
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Affiliation(s)
- Bingwen Liu
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, Hunan, China
| | - Min Li
- Department of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, Hunan, China
| | - Xuan Guan
- Department of Internal Medicine, AdventHealth Orlando, Orlando, Florida, USA.
| | - Yufei Xiang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, Hunan, China.
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