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Walmsley CS, Schoepflin Z, De Brabandt C, Rangachari D, Berwick S, Patell R. Hemophagocytic lymphohistiocytosis associated with immune checkpoint inhibitor use: A review of the current knowledge and future directions. Blood Cells Mol Dis 2024; 110:102896. [PMID: 39366077 DOI: 10.1016/j.bcmd.2024.102896] [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: 08/10/2024] [Revised: 09/18/2024] [Accepted: 09/24/2024] [Indexed: 10/06/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe and often lethal inflammatory syndrome characterized by excessive immune activation leading to fever, cytopenias, and multiorgan involvement. Immune checkpoint inhibitors (ICIs) are central to many contemporary cancer regimens, but their use is associated with immune-related adverse events. Here, we report a case of ICI-induced HLH successfully treated with single agent dexamethasone and provide a scoping review of the literature for cases of ICI-induced HLH with a focus on treatment strategies and outcomes. Using the Medline database, we searched for cases of ICI-associated HLH, with a total of 51 cases reported between 2017 and 2023. Our results underscore the severe nature of this disease, with a 13.7 % mortality rate across 51 case reports. Treatment strategies for ICI-induced HLH were variable: steroids alone (56.9 %), steroids with etoposide (17.6 %), steroids with tociluzumab (11.8 %), among other combinations. Our literature review indicates that steroids alone may be sufficient treatment in some cases of ICI-HLH, with comparable mortality with steroids alone (n = 29) (13.8 %) to that of cases treated with both steroids and immunomodulators (n = 15, 13.3 %). Moreover, all patients treated with steroids and tocilizumab survived (n = 6), suggesting that tocilizumab may be a reasonable next line of therapy when steroid monotherapy proves inadequate. We propose an outline for investigation and treatment of this rare complication of ICI use. Finally, we discuss possible future approaches to develop evidence-based strategies for the diagnosis and management of ICI-induced HLH including the importance of integrating the role of patient community involvement.
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Affiliation(s)
- Charlotte S Walmsley
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Zachary Schoepflin
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Charlotte De Brabandt
- Breast Cancer Center, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Patient Ambassador Program, American Cancer Society, Boston, MA, United States of America
| | - Deepa Rangachari
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Shana Berwick
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Rushad Patell
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America.
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Yin D, Wang J, Wang Z. The effectiveness of the doxorubicin-etoposide-methylprednisolone regimen for adult HLH secondary to rheumatic disease. Ann Hematol 2024; 103:3463-3472. [PMID: 38772957 DOI: 10.1007/s00277-024-05796-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
To investigate the efficacy of the doxorubicin-etoposide-methylprednisolone, DEP) regimen as an effective treatment for adult Hemophagocytic Lymphohistiocytosis secondary to rheumatic disease and analyze prognosis in these patients. Fifty-eight adult patients diagnosed with Hemophagocytic Lymphohistiocytosis secondary to rheumatic disease admitted to Beijing Friendship Hospital from 1st Jan. 2018 to 31st Dec. 2022 were retrospectively included in this study. Patients were grouped according to previous treatment. Clinical data and laboratory characteristics of patients were retrospectively analyzed. The efficacy was evaluated every 2 weeks after initiating the first course of the DEP regimen and until the last inpatient or 31st Dec. 2023. 26 patients were included in Group A and 32 patients were included in Group B due to the previous treatment. After the first course of the DEP regimen, the overall response rate of all patients was 82.8%, with 13.8% in complete response and 69% in partial response. There was no significant statistical objective response rate between the two groups after the DEP regimen, except at 2-week. Serum ferritin, sCD25, ALT, AST, and DBIL concentrations were significantly lower at 2, 4 and 6-week than pre-treatment (P < 0.05). The overall mortality rate is 20.7% (12/58). Importantly, advanced age, initial level of HB and PLT, and central nervous system (CNS) involvement were independent poor risk factors affecting OS in bivariate analysis. The DEP regimen is effective for adult HLH secondary rheumatic disease with a high overall rate and accepted side effects.
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Affiliation(s)
- Dongfei Yin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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Hu J, Wang J, Wang Z. The efficacy and safety of chidamide in combination with etoposide and glucocorticoids for the treatment of hemophagocytic lymphohistiocytosis in adult patients: an open-label, single-center study. Front Immunol 2024; 15:1415597. [PMID: 39040100 PMCID: PMC11260630 DOI: 10.3389/fimmu.2024.1415597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/26/2024] [Indexed: 07/24/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by hyperinflammation and organ failure, with a high mortality rate. Current first-line treatments for adult patients have limited efficacy and significant toxicity. The novel selective histone deacetylase inhibitor (HDACi), chidamide, has shown promise in preclinical studies for the potential treatment of HLH. Methods An open-label, single-center study was conducted to evaluate the efficacy and safety of chidamide in combination with etoposide and glucocorticoids for the treatment of HLH in adult patients. Seventeen patients who fulfilled at least five of the eight HLH-2004 criteria were enrolled and treated with the combination therapy. The primary outcome was overall response rate (ORR), and secondary outcomes included survival, safety and tolerability, and changes in laboratory indicators. Results A total of 17 HLH patients who met the inclusion criteria were enrolled in this study, with a male to female ratio of 1.8:1. The age range at enrollment was 31 to 71 years old, with a median age of 52 years old. The ORR was 76.5% (13/17 patients), with a complete response (CR) rate of 17.6% (3/17 patients) and a partial response (PR) rate of 58.8% (10/17 patients). The median overall survival (OS) was not achieved, with OS at 6 months and 12 months being 81% and 65%, respectively. The median progression free survival (PFS) was not achieved, with PFS at 6 months and 12 months being 68% and 55%, respectively. Hematologic toxicities is the most common. Safety profile was favorable, with very few cases of grade 3/4 toxicities observed. The results showed that the levels of sCD25, platelets, aspartate aminotransferase, lactate dehydrogenase, and albumin in these patients were significantly improved 3 weeks after treatment. Conclusion The addition of chidamide to etoposide and glucocorticoids may be a promising new treatment option for patients with HLH, with a high ORR, manageable safety profile, and significant improvement in laboratory indicators. Further research is needed to confirm these findings and determine the optimal dosing and duration of therapy.
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Affiliation(s)
| | | | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Wang H, Wang Y, Liu H, Li X, Sun C, Pang Z, Zhang B, Hu Y. Ruxolitinib-loaded cytokine nanosponge alleviated the cytokine storm and dampened macrophage overactivation for the treatment of hemophagocytic lymphohistiocytosis. Int J Pharm 2024; 657:124127. [PMID: 38621611 DOI: 10.1016/j.ijpharm.2024.124127] [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: 02/17/2024] [Revised: 03/30/2024] [Accepted: 04/13/2024] [Indexed: 04/17/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening clinical syndrome characterized by a positive feedback loop between cytokine storm and macrophages and lymphocytes overactivation, which could serve as a valid therapeutic target for HLH treatment. In this study, the clinically extensively used JAK1/2 inhibitor ruxolitinib was encapsulated into macrophage membrane-coated nanoparticles (M@NP-R) with high drug-loading efficiency for targeted HLH treatment. In vitro and in vivo studies demonstrated that M@NP-R not only efficiently adsorbed extracellular proinflammation cytokines, like IFN-γ and IL-6 to alleviate the cytokine storm, but also effectively dampened macrophage activation and proliferation by intracellular JAK/STAT signaling pathway inhibition. M@NP-R treatment significantly ameliorated the clinical and laboratory manifestations of HLH in mouse models, including trilineage cytopenia, hypercytokinemia, organomegaly, hepatorenal dysfunction, and tissue inflammation. Importantly, M@NP-R significantly enhanced the survival of the lethal HLH mice. Altogether, M@NP-R successfully blocked the positive feedback loop between the cytokine storm and macrophage overactivation by depleting extracellular inflammatory cytokines and inhibiting the intracellular JAK/STAT signaling pathway, both of which worked synergistically in HLH treatment. As ruxolitinib has already been extensively used in clinics with favorable safety, and M@NP is biodegradable and highly biocompatible, M@NP-R has good prospects for clinical translation.
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Affiliation(s)
- Honglan Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Yiwei Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Huiwen Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Xuejing Li
- School of Pharmacy, Fudan University, Key Laboratory of Smart Drug Delivery, Ministry of Education, 826 Zhangheng Road, Shanghai 201203, China
| | - Chunyan Sun
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Zhiqing Pang
- School of Pharmacy, Fudan University, Key Laboratory of Smart Drug Delivery, Ministry of Education, 826 Zhangheng Road, Shanghai 201203, China.
| | - Bo Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education.
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Chen L, Wang J, Wang Z. PD-1 Blockade-Induced Hemophagocytic Lymphohistiocytosis, a Dilemma Therapeutic Outcome in 2 Patients with CAEBV: A Case Series. Infect Drug Resist 2024; 17:1545-1550. [PMID: 38650754 PMCID: PMC11034567 DOI: 10.2147/idr.s441460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), whether primary or secondary, is a rare and fatal clinical syndrome of uncontrolled immune activation and inflammatory cascade. Immune checkpoint inhibitors (ICIs) induced HLH has no standard diagnostic and treatment guidelines. Early diagnosis and appropriate treatment according to different disease backgrounds are crucial. Herein, we first report 2 cases of patients with chronic active Epstein-Barr virus infection (CAEBV) who developed HLH after the use of sintilimab, a monoclonal antibody against programmed cell death protein 1 (PD-1), and the DEP (liposomal doxorubicin, etoposide, methylprednisolone) chemotherapy regimen in combination with ruxolitinib were used to successfully control the disease.
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Affiliation(s)
- LeiLei Chen
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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Feng C, Hua Z, He L, Yao S, Zou H, Zhu Y, Wang Z, Wang Y. A convenient and practical index for predicting the induction response in adult patients with hemophagocytic lymphohistiocytosis: ferritin/platelet ratio. Ann Hematol 2024; 103:715-723. [PMID: 38197929 PMCID: PMC10867095 DOI: 10.1007/s00277-023-05606-7] [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: 10/18/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome with high mortality rate. The response to induction therapy is an important factor affecting survival. The purpose is to investigate laboratory predictors for induction response in adult patients with HLH, which are convenient, practical, and timeliness. Clinical data from January 2017 to December 2020 was retrospectively analyzed, and 269 patients were included. Patients were divided into remission and non-remission groups according to their induction response, 177 in the remission group, and 92 in the non-remission group. We reviewed general characteristics and analyzed the predictive value of serum ferritin, triglycerides, alanine aminotransferase (ALT), and blood cells before and 1-4 weeks after induction therapy for induction response by univariate analysis, ROC curves, etc. There was a correlation between serum ferritin, ALT, leukocytes, neutrophils, hemoglobin, platelets, and induction response (P < 0.05). Serum ferritin and platelets 1-4 weeks after induction therapy, respectively, might be a good predictor for induction response in adults with HLH, with AUC values close to or greater than 0.7. We established a new clinical model of the ferritin/platelet ratio. The results showed that the ferritin/platelet ratio at 1-4 weeks after induction therapy might be a practical index for predicting induction response, which significantly improved the area under the ROC curve (AUC > 0.75). Patients with a ferritin/platelet ratio > 16.08 at 2 weeks after induction therapy may have a relatively poor induction response. Ferritin/platelet ratio after induction therapy can be a good predictor for induction response in adult patients with HLH.
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Affiliation(s)
- Cuicui Feng
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
- Department of Hematology, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, 100029, China
| | - Zhengjie Hua
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Lingbo He
- Department of General Medicine, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Shuyan Yao
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Heshan Zou
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Yingxin Zhu
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China.
| | - Yini Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China.
- Department of General Medicine, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, 100050, China.
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Knauft J, Schenk T, Ernst T, Schnetzke U, Hochhaus A, La Rosée P, Birndt S. Lymphoma-associated hemophagocytic lymphohistiocytosis (LA-HLH): a scoping review unveils clinical and diagnostic patterns of a lymphoma subgroup with poor prognosis. Leukemia 2024; 38:235-249. [PMID: 38238443 PMCID: PMC10844097 DOI: 10.1038/s41375-024-02135-8] [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: 11/03/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome driven by pathologic activation of cytotoxic T-lymphocytes and macrophages. Despite advances in diagnostics and management, adult patients with lymphoma-associated HLH (LA-HLH) harbor particularly poor prognosis and optimal treatment remains challenging. As systematic data on LA-HLH are scarce, we aimed to synthesize research evidence by thorough analysis of the published literature in PubMed (MEDLINE-database) within the context of a scoping review. Of 595 search results, 132 articles providing information on 542 patients were reviewed and analyzed. Median patient age was 60 years (range, 18-98) with male predominance (62.7%). B- and T-NHL were equally represented (45.6% and 45.2%), Hodgkin's lymphoma was reported in 8.9% of the cases. The majority of patients (91.6%) presented in Ann-Arbor-Stages III and IV, and bone marrow infiltration was observed in a significant proportion of patients (61.5%). Soluble CD25 levels were markedly elevated (median 10,000 U/ml), with levels beyond 10,000 U/ml indicating unfavorable prognosis for 30-day and overall survival. 66.8% of the patients died after median 5.1 months. LA-HLH remains a clinical challenge requiring specialized management. Timely diagnosis and appropriate lymphoma-specific treatment are of utmost importance to enhance patient outcomes.
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Affiliation(s)
- Johanna Knauft
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Schenk
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Ernst
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Ulf Schnetzke
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Onkologie, Hämatologie, Immunologie, Infektiologie und Palliativmedizin, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Sebastian Birndt
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany.
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Rahman AU, Baig F, Javid Chaudhary UI, Ashraf MB, Jawaid MD, Chaudary A, Tariq M. Hemophagocytic Lymphohistiocytosis Associated With Human Herpesvirus-6 (HHV-6) Infection in an Immunocompetent Adult: A Case Report. Cureus 2024; 16:e54299. [PMID: 38496135 PMCID: PMC10944635 DOI: 10.7759/cureus.54299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder characterized by extreme immune activation and excessive inflammation. It has been reported in patients with familial cases, immunodeficiencies, malignancies, stem cell transplants, and viral etiologies. This report describes acquired HLH associated with Human herpesvirus-6 (HHV-6) infection in a 76-year-old previously healthy male. The patient was admitted to the hospital due to fever, chills, and abdominal pain. The diagnostic workup revealed gallbladder wall thickening on imaging, concerning for cholecystitis. The patient was started on treatment for sepsis. Further clinical deterioration led to an extensive infectious workup. The patient was found to have elevated soluble IL-2Ra levels, and a bone marrow biopsy was performed, which revealed HLH. A positive HHV-6 polymerase chain reaction in the cerebrospinal fluid and serum confirmed the viral infection. Treatment involved the initiation of high-dose steroids, etoposide, and ganciclovir. Despite these interventions, the patient's clinical status worsened, leading to the implementation of comfort measures, and the patient eventually died. This case underscores the importance of considering HHV-6 as a potential cause of HLH in immunocompetent adults. From this case, we infer that a heightened level of vigilance is necessary to recognize and intervene in this challenging condition promptly.
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Affiliation(s)
- Ateeb Ur Rahman
- Department of Internal Medicine, Penn State Health, Camp Hill, USA
| | - Fahad Baig
- Department of Medicine, Rashid Latif Medical College, Lahore, PAK
| | | | | | | | - Amna Chaudary
- Department of Internal Medicine, Penn State Health, Camp Hill, PAK
| | - Munim Tariq
- Department of Internal Medicine, The Rotherham NHS Foundation Trust, Sheffield, GBR
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Marsh RA. Salvage Therapy and Allogeneic Hematopoietic Cell Transplantation for the Severe Cytokine Storm Syndrome of Hemophagocytic Lymphohistiocytosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:611-622. [PMID: 39117843 DOI: 10.1007/978-3-031-59815-9_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) can be considered as a severe cytokine storm syndrome disorder. HLH typically manifests as a life-threatening inflammatory syndrome characterized by fevers, cytopenias, hepatosplenomegaly, and various other accompanying manifestations such as coagulopathy, hepatitis or liver failure, seizures or altered mental status, and even multi-organ failure. Standard up-front treatments do not always bring HLH into remission or maintain adequate response, and salvage or alternative therapies are often needed. For patients with genetic diseases that cause HLH, curative allogeneic hematopoietic cell transplantation is usually offered to prevent future episodes of life-threatening HLH. Here, we will discuss the options and approaches for salvage therapy and hematopoietic cell transplantation for patients with HLH.
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Affiliation(s)
- Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA.
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Zoref-Lorenz A, Lehmberg K, Jordan M. Hemophagocytic Lymphohistiocytosis in the Context of Hematological Malignancies and Solid Tumors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:429-440. [PMID: 39117831 DOI: 10.1007/978-3-031-59815-9_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has been described for decades in association with malignancies (M-HLH). While its mechanism is unknown, M-HLH has a poor prognosis, ranging from 10% to 30% overall survival. Mature T-cell lymphomas, diffuse large B-cell lymphoma, and Hodgkin lymphoma, with or without viral co-triggers such as Epstein-Barr virus, are among the most frequent underlying entities. Most M-HLH cases occur at the presentation of malignancy, but they may also occur during therapy as a result of immune compromise from chemotherapy (HLH in the context of immune compromise, IC-HLH) and (typically) disordered response to infection or after immune-activating therapies (Rx-HLH, also known as cytokine release syndrome, CRS). IC-HLH typically occurs months after diagnosis in the context of fungal, bacterial, or viral infection, though it may occur without an apparent trigger. Rx-HLH can be associated with checkpoint blockade, chimeric antigen receptor T-cell therapy, or bispecific T-cell engaging therapy. Until recently, M-HLH diagnosis and treatment strategies were extrapolated from familial HLH (F-HLH), though optimized diagnostic and therapeutic treatment strategies are emerging.
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Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, Clinic of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Michael Jordan
- Divisions of Immunobiology and Bone Marrow Transplantation/Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Henter JI, von Bahr Greenwood T. Etoposide Therapy of Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:525-551. [PMID: 39117837 DOI: 10.1007/978-3-031-59815-9_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Etoposide has revolutionized the treatment of primary as well as secondary hemophagocytic lymphohistiocytosis (HLH), and it is, together with corticosteroids, the most widely used therapy for HLH. In the early 1980s, long-term survival in primary HLH was <5% but with the etoposide-/dexamethasone-based protocols HLH-94 and HLH-2004, in combination with stem cell transplantation, 5-year survival increased dramatically to around 60% in primary HLH, and based on analyses from the HLH-2004 study, there is likely room for further improvement. Biologically, etoposide administration results in potent selective deletion of activated T cells as well as efficient suppression of inflammatory cytokine production. Moreover, etoposide has also been reported to promote programmed cell death (apoptosis) rather than proinflammatory lytic cell death (pyroptosis), conceivably ameliorating subsequent systemic inflammation, i.e., a treatment very suitable for cytokine storm syndromes (CSS). The combination of etoposide and corticosteroids may also be beneficial in cases of severe or refractory secondary HLH (sHLH) with imminent organ failure, such as infection-associated HLH caused by Epstein-Barr virus (EBV) or malignancy-triggered HLH. In CSS associated with rheumatic diseases (macrophage activation syndrome, MAS or MAS-HLH), etoposide is currently used as second- or third-line therapy. Recent studies suggest that etoposide perhaps should be part of an aggressive therapeutic intervention for patients with severe refractory or relapsing MAS, in particular if there is CNS involvement. Importantly, awareness of sHLH must be further increased since treatment of sHLH is often delayed, thereby missing the window of opportunity for a timely, effective, and potentially life-saving HLH-directed treatment.
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Affiliation(s)
- Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, and Astrid Lindgren Children's Hospital, Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Tatiana von Bahr Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, and Astrid Lindgren Children's Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
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Song D, Wang J, Zhang J, Hu J, Wu C, Wang Z. Case Report: HAVCR2 mutation-associated Hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1271324. [PMID: 38077348 PMCID: PMC10701531 DOI: 10.3389/fimmu.2023.1271324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
Germline HAVCR2 mutation has been reported to be associated with subcutaneous panniculitis-like T-cell lymphoma (SPTCL) leading to Hemophagocytic lymphohistiocytosis (HLH). Several studies have indicated that HAVCR2 mutation can cause HLH even in the absence of lymphoma, though the exact mechanism remains unclear. In this article, we reported five cases of HAVCR2 mutation-associated HLH. Our analysis revealed an elevated level of IL-1RA in the serum of these patients. Furthermore, we investigated the potential mechanisms underlying HLH associated with HAVCR2 mutation based on changes in cytokine levels. Our findings suggest that HAVCR2 mutation may represent a distinct genetic defect underlying HLH, differing from traditional primary HLH.
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Affiliation(s)
| | | | | | | | | | - Zhao Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
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Xiao L, Zhang Y, Xu X, Dou Y, Guan X, Guo Y, Wen X, Meng Y, Liao M, Hu Q, Yu J. Predictive model for early death risk in pediatric hemophagocytic lymphohistiocytosis patients based on machine learning. Heliyon 2023; 9:e22202. [PMID: 38045172 PMCID: PMC10692822 DOI: 10.1016/j.heliyon.2023.e22202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023] Open
Abstract
Background Hemophagocytic Lymphohistiocytosis (HLH) is a rare and life-threatening disease in children, with a high early mortality rate. This study aimed to construct machine learning model to predict the risk of early death using clinical indicators at the time of HLH diagnosis. Methods This observational cohort study was conducted at the National Clinical Research Center for Child Health and Disease. Data was collected from pediatric HLH patients diagnosed by the HLH-2004 protocol between January 2006 and December 2022. Six machine learning models were constructed using the Least Absolute Shrinkage and Selection Operator (LASSO) to select key clinical indicators for model construction. Results The study included 587 pediatric HLH patients, and the early mortality rate was 28.45 %. The logistic and XGBoost model with the best performance after feature screening were selected to predict early death of HLH patients. The logistic model had an AUC of 0.915 and an accuracy of 0.863, while the XGBoost model had an AUC of 0.889 and an accuracy of 0.829. The risk factors most associated with early death were the absence of immunochemotherapy, decreased TC levels, increased BUN and total bilirubin, and prolonged TT. We developed an online calculator tool for predicting the probability of early death in children with HLH. Conclusions We developed the first web-based early mortality prediction tool for pediatric HLH to assist clinicians in risk stratification at diagnosis and in developing personalized treatment protocols. This study is registered on the China Clinical Trials Registry platform (ChiCTR2200061315).
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Affiliation(s)
- Li Xiao
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yang Zhang
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Ximing Xu
- Big Data Center for Children's Medical Care, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Dou
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Xianmin Guan
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yuxia Guo
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Xianhao Wen
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yan Meng
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Meiling Liao
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Qinshi Hu
- Big Data Center for Children's Medical Care, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Yu
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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Li J, Cao C, Lu S, Rong L, Kang M, Fang Y. Successful treatment of systemic EBV-positive T-cell lymphoma of childhood using the ruxolitinib combined with L-DEP regimen chemotherapy followed by haploidentical allogeneic hematopoietic stem cell transplantation. Ann Hematol 2023; 102:2955-2957. [PMID: 37490113 DOI: 10.1007/s00277-023-05298-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/20/2022] [Indexed: 07/26/2023]
Affiliation(s)
- Jian Li
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210008, China
| | - Chunyan Cao
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210008, China
| | - Shifeng Lu
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210008, China
| | - LiuCheng Rong
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210008, China
| | - Meiyun Kang
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210008, China
| | - Yongjun Fang
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China.
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, 210008, China.
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15
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An JH, Ahn JH. Postpartum hemophagocytic lymphohistiocytosis: A case report. World J Clin Cases 2023; 11:6183-6188. [PMID: 37731572 PMCID: PMC10507548 DOI: 10.12998/wjcc.v11.i26.6183] [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: 04/26/2023] [Revised: 07/12/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Postpartum hemophagocytic lymphohistiocytosis (HLH) is a rare disease with unclear pathophysiology. It is a secondary HLH diagnosed using the pediatric diagnostic criteria; however, the clinical diagnosis of postpartum HLH remains challenging. Hence, HLH may remain undiagnosed, leading to poor patient prognosis. Therefore, improvements in the accuracy of postpartum HLH diagnoses and treatments are necessary. CASE SUMMARY We report the case of a 40-year-old female with postpartum HLH. The patient attended the postpartum care center for 3 wk after giving birth and underwent needle aspiration due to thyroid gland enlargement 11 d before an emergency department visit precipitated by fever and abdominal pain. Since no abnormal emergency room findings were noted, the patient was discharged with a prescription for broad-spectrum antibiotics. Three days later, she returned to the emergency room in a hemodynamically unstable state and was admitted to the intensive care unit with suspected sepsis or hematologic disease. The patient was treated, without effect, for sepsis using broad-spectrum antibiotics, and for suspected hematologic disease with steroid therapy. However, she died due to rapidly worsening symptoms. CONCLUSION Rapid recognition and appropriate treatment of postpartum HLH are needed to improve the prognosis.
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Affiliation(s)
- Ju Ho An
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon 16499, Gyeonggi-do, South Korea
| | - Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon 16499, Gyeonggi-do, South Korea
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16
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He L, Yang C, Wang Y. Biological therapies for hemophagocytic lymphohistiocytosis: current knowledge and future perspectives. Expert Opin Biol Ther 2023; 23:1005-1013. [PMID: 37614018 DOI: 10.1080/14712598.2023.2251885] [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: 06/25/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome with a dismal prognosis. The underlying causes of HLH are diverse. However, the overabundance of cytokines was shared by all forms of HLH. Cytokine-targeted biotherapies have been increasingly used in HLH treatment. AREAS COVERED In this review, we aim to provide an overview of biological treatment options for HLH. EXPERT OPINION Biological therapies offer alternative treatment options for patients with refractory/relapsed HLH or who are intolerant to conventional chemotherapies. As a complement to traditional treatment, biological agents improve response rates, maintain more protracted periods of remission, and reduce treatment related toxicity. A combination of biological agents may be a promising direction for HLH treatment. However, they may induce HLH to deteriorate and even trigger HLH.
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Affiliation(s)
- Lingbo He
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chun Yang
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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17
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Wang W, Yang Y, Ma H, He L, Zhou C, Wang D, Zhao Y, Zhang Q, Zeng J, Li Z, Wang T, Zhang R. Epstein-Barr virus-positive diffuse large B-cell lymphoma onset as familial hemophagocytic lymphohistiocytosis in an infant. Pediatr Blood Cancer 2023; 70:e30170. [PMID: 36565278 DOI: 10.1002/pbc.30170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Wenqian Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ying Yang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics, Capital Medical University; Key Laboratory of Major Diseases 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 Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lejian He
- Department of Pathology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chunju Zhou
- Department of Pathology, 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 Diseases 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 Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qing Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jiansheng Zeng
- Pediatric Intensive Care Unit, 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
| | - Tianyou Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics, Capital Medical University; Key Laboratory of Major Diseases 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 Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Sacco KA, Notarangelo LD, Delmonte OM. When to suspect inborn errors of immunity in Epstein-Barr virus-related lymphoproliferative disorders. Clin Microbiol Infect 2023; 29:457-462. [PMID: 36209991 PMCID: PMC10066820 DOI: 10.1016/j.cmi.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/20/2022] [Accepted: 10/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND More than 95% of humans have been infected with Epstein-Barr virus (EBV) and develop anti-EBV IgG antibodies, conferring immunity. However, among specific populations, EBV may induce a range of B-cell lymphoproliferative disorders (LPDs). EBV may also contribute to T-cell and natural killer (NK)-cell lymphoproliferation. The immune system is essential to prevent infection and development of cancer. Inborn errors of immunity (IEIs) are a heterogenous group of more than 450 genetic disorders predisposing to severe and/or recurrent infection, autoimmunity, autoinflammation, or early-onset/severe neoplasia or lymphoproliferation. Monogenic disorders of T-cell and B-cell signalling are classic IEIs that predispose to EBV-associated LPDs. OBJECTIVES We aimed to outline the various clinical manifestations of EBV-associated LPDs and the underlying IEIs associated with such presentations and discuss the recommended management and therapeutic options pertaining to these disorders. SOURCES We searched PubMed, Embase, and Web of Science Core Collection on 30 September 2021. Clinical studies, systematic reviews, narrative reviews, and case reports were identified through search strategy and cross reference from primary literature. CONTENT Effective T-cell and NK-cell cytotoxicity towards EBV-infected B cells relies on intact MAGT1-dependent NKG2D pathways and signalling lymphocyte activation molecular-associated protein-dependent signalling lymphocyte activation molecular receptors. The interaction between CD27 and CD70 is also critical to drive the expansion of EBV-specific T cells. IEIs due to T-cell and B-cell signalling defects and/or impaired T-cell and NK-cell cytotoxicity predispose to EBV-related lymphoproliferation. This includes classic disorders such as X-linked lymphoproliferative disease 1 (due to SH2D1A mutations), X-linked lymphoproliferative disease 2 (XIAP), and other genetic diseases, such as ITK, MAGT1, CD27, CD70, CTPS1, RASGRP1, and CORO1A deficiencies. EBV-driven lymphoproliferation may manifest to a lesser degree in MST1/STK4, DOCK8, STIM1, CORO1A, IL21R, PIK3CD gain-of-function, and PI3KR1 deficiencies. IMPLICATIONS Early screening for IEIs is indicated in cases of EBV-related lymphoproliferation because different forms of IEIs have specific prognostic and therapeutic implications.
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Affiliation(s)
- Keith A Sacco
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, USA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, USA
| | - Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, USA.
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19
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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20
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La Marle S, Richard-Colmant G, Fauvernier M, Ghesquières H, Hot A, Sève P, Jamilloux Y. Mortality and Associated Causes in Hemophagocytic Lymphohistiocytosis: A Multiple-Cause-of-Death Analysis in France. J Clin Med 2023; 12:jcm12041696. [PMID: 36836229 PMCID: PMC9967667 DOI: 10.3390/jcm12041696] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/26/2023] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome with an overall mortality rate of 40%. A multiple-cause-of-death analysis allows for the characterization of mortality and associated causes over an extended period. Death certificates, collected between 2000 and 2016 by the French Epidemiological Centre for the Medical Causes of Death (CepiDC, Inserm), containing the ICD10 codes for HLH (D76.1/2), were used to calculate HLH-related mortality rates and to compare them with the general population (observed/expected ratios, O/E). HLH was mentioned in 2072 death certificates as the underlying cause of death (UCD, n = 232) or as a non-underlying cause of death (NUCD, n = 1840). The mean age at death was 62.4 years. The age-standardized mortality rate was 1.93/million person-years and increased over the study period. When HLH was an NUCD, the most frequently associated UCDs were hematological diseases (42%), infections (39.4%), and solid tumors (10.4%). As compared to the general population, HLH decedents were more likely to have associated CMV infections or hematological diseases. The increase in mean age at death over the study period indicates progress in diagnostic and therapeutic management. This study suggests that the prognosis of HLH may be at least partially related to coexisting infections and hematological malignancies (either as causes of HLH or as complications).
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Affiliation(s)
- Solène La Marle
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Gaëlle Richard-Colmant
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Mathieu Fauvernier
- Département de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69000 Lyon, France
| | - Hervé Ghesquières
- Département d’Hématologie, Hôpital Lyon Sud—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69495 Lyon, France
| | - Arnaud Hot
- Département de Médecine Interne, Hôpital Edouard Herriot—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69003 Lyon, France
| | - Pascal Sève
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Yvan Jamilloux
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
- Lyon Immunopathology Federation (LIFE), Université Claude Bernard-Lyon 1, 69000 Lyon, France
- Correspondence: ; Tel.: +33-426-732-636
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21
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Abstract
Cytokine storm syndrome (CSS), which is frequently fatal, has garnered increased attention with the ongoing coronavirus pandemic. A variety of hyperinflammatory conditions associated with multiorgan system failure can be lumped under the CSS umbrella, including familial hemophagocytic lymphohistiocytosis (HLH) and secondary HLH associated with infections, hematologic malignancies, and autoimmune and autoinflammatory disorders, in which case CSS is termed macrophage activation syndrome (MAS). Various classification and diagnostic CSS criteria exist and include clinical, laboratory, pathologic, and genetic features. Familial HLH results from cytolytic homozygous genetic defects in the perforin pathway employed by cytotoxic CD8 T lymphocytes and natural killer (NK) cells. Similarly, NK cell dysfunction is often present in secondary HLH and MAS, and heterozygous mutations in familial HLH genes are frequently present. Targeting overly active lymphocytes and macrophages with etoposide and glucocorticoids is the standard for treating HLH; however, more targeted and safer anticytokine (e.g., anti-interleukin-1, -6) approaches are gaining traction as effective alternatives.
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Affiliation(s)
- Randy Q Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA; .,Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Gaurav Goyal
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - W Winn Chatham
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
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22
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Cheng W, Wang L, Gao X, Duan L, Shu Y, Qiu H. Prognostic value of lipid profile in adult hemophagocytic lymphohistiocytosis. Front Oncol 2023; 13:1083088. [PMID: 36895490 PMCID: PMC9988898 DOI: 10.3389/fonc.2023.1083088] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/08/2023] [Indexed: 02/23/2023] Open
Abstract
Background Adult secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare clinical syndrome with a high mortality rate. Currently, there are no feasible prognostic factors to clinically predict untreated sHLH patients' prognosis. Our objective was to characterize the lipid profile of adult sHLH patients and to determine the relationship with overall survival. Methods We retrospectively analyzed 247 patients with newly diagnosed sHLH from January 2017 to January 2022 according to the HLH-2004 criteria. Multivariate Cox regression analyses and restricted cubic splines were conducted to evaluate the prognostic value of the lipid profile. Results The median age of all patients was 52 years, and the commonest cause of sHLH in our cohort was malignancy. During a median follow-up of 88 (interquartile ranges, 22-490) days, 154 deaths occurred. The univariate analysis confirmed total cholesterol (TC) ≤ 3 mmol/L, triglycerides (TG) > 3.08 mmol/L, high-density lipoprotein cholesterol (HDL-c) ≤ 0.52 mmol/L, and low-density lipoprotein cholesterol (LDL-c) ≤ 2.17 mmol/L were associated with an inferior survival. In a multivariate model, HDL-c, hemoglobin, platelet, fibrinogen, and soluble interleukin-2 receptor were considered as independent factors. Additionally, the restricted cubic spline analyses indicated an inverse linear association between HDL-c and the risk of mortality in sHLH. Conclusion Lipid profiles, which were low-cost and readily available promising biomarkers, were strongly associated with the overall survival in adult sHLH patients.
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Affiliation(s)
- Wanying Cheng
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Lingling Wang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Hematology, Wuxi People's Hospital, Wuxi, China
| | - Xin Gao
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Limin Duan
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yongqian Shu
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Hongxia Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
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23
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Kong Q, Wang J, Zhang Y, Hu J, Yu M, Wu L, Wang Z. Misdiagnosis of adult primary hemophagocytic lymphohistiocytosis as NK/T-cell lymphoma: A case report. EJHAEM 2022; 3:1367-1373. [PMID: 36467838 PMCID: PMC9713033 DOI: 10.1002/jha2.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 06/17/2023]
Abstract
We reported a case of a 19-year-old male patient with central nervous system symptoms as the main clinical manifestations, and multiple intracranial and abdominal occupying lesions visualized by imaging examinations, who was initially misdiagnosed as NK/T-cell lymphoma but poorly responsive to the treatment. Finally, he was diagnosed as familial hemophagocytic lymphohistiocytosis type-2 by genome sequencing, perforin test and pedigree study. The patient survived well after allogeneic hematopoietic stem cell transplantation. Central nervous system symptoms could be the main clinical manifestations in patients with primary hemophagocytic lymphohistiocytosis , whose early-stage manifestations of blood system were usually atypical, easily leading to misdiagnosis. In clinical practice, primary hemophagocytic lymphohistiocytosis should be considered in patients with central nervous system symptoms and unknown causes. The combination of rapid immunological function test and genome sequencing contributes to the diagnosis of primary hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Qi Kong
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Jingshi Wang
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Yanlin Zhang
- Department of PathologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Junxia Hu
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Mingzhu Yu
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Lin Wu
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Zhao Wang
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
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24
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Xu QY, Yang HY, Li MW, He ZD, Hong HY, Peng ZG. Sintilimab combined with chidamide in the treatment of extranodal nature killer/T-cell lymphoma with secondary hemophagocytic lymphohistiocytosis: Two case reports and literature review. Medicine (Baltimore) 2022; 101:e30731. [PMID: 36197207 PMCID: PMC9509087 DOI: 10.1097/md.0000000000030731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Extranodal nature killer/T-cell lymphoma (ENKTL) failing in asparaginase-containing treatments is fatal, it has a higher mortality rate when accompanied by secondary hemophagocytic lymphohistiocytosis (HLH). The study reported 2 ENKTL-related HLH patients. PATIENT CONCERNS Patient 1 visited for nasal congestion and runny nose for 6 months then got a fever and serious myelosuppression after P-GEP (pegaspargase, gemcitabine, etoposide, and methylprednisolone) chemotherapy. Patient 2 complained of painless lymphadenectasis in the right neck for 4 months and experienced recurrent fever and poor performance status after 3 cycles of P-Gemox (pegaspargase, gemcitabine, and oxaliplatin) chemotherapy. DIAGNOSES Patient 1 and patient 2 were diagnosed as ENKTL failing in asparaginase-based chemotherapy and involving secondary HLH. INTERVENTIONS The dose of chidamide was 20 mg twice a week for 2 weeks and sintilimab was 200 mg once every 3 weeks. OUTCOMES ENKTL was relieved and the HLH was resolved after the therapy of sintilimab and chidamide. The patients had achieved durable survival without immune-related adverse events. LESSONS ENKTL-related HLH needs early diagnosis and treatment. The combined strategy of sintilimab plus chidamide help deal with HLH and solve ENKTL, it may be a useful treatment option for ENKTL-related HLH.
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Affiliation(s)
- Qing-Yuan Xu
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, P. R. China
| | - Hai-Yan Yang
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, P. R. China
| | - Mei-Wei Li
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, P. R. China
| | - Zhen-Dong He
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, P. R. China
| | - Hao-Yuan Hong
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, P. R. China
| | - Zhi-Gang Peng
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, P. R. China
- *Correspondence: Zhi-Gang Peng, Department of Oncology, First Affiliated Hospital of Guangxi Medical University, No.6 Shuangyong Road, Qingxiu District, Nanning, Guangxi Zhuang Autonomous Region, P. R. China (e-mail: )
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Chen L, Wang J, Wang Z. L-DEP regimen is effective as an initial therapy for adult EBV-HLH. Ann Hematol 2022; 101:2461-2470. [PMID: 36094533 DOI: 10.1007/s00277-022-04946-0] [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: 05/19/2022] [Accepted: 07/30/2022] [Indexed: 11/01/2022]
Abstract
We performed a single-center, prospective trial to investigate the efficacy of PEG- asparaginase combined with liposomal doxorubicin, etoposide, and methylprednisolone (L-DEP) as an initial therapy for Epstein-Barr virus driven hemophagocytic lymphohistiocytosis (EBV-HLH). None of the patients received any chemotherapy after the diagnosis of EBV-HLH between September 2019 and September 2021. The efficacy was evaluated 2 weeks and 4 weeks after initiating L-DEP primary therapy. Forty-seven eligible patients with EBV-HLH were enrolled. The overall response rate (ORR) was 80.9% (38/47, 12 in clinical CR, 26 in clinical PR) at 2 weeks after the L-DEP regimen; at 4 weeks, the ORR was 75.6% (34/45, 21 in clinical CR, 13 in clinical PR). EBV-DNA loads in blood and plasma were significantly decreased 2 and 4 weeks after the L-DEP regimen (P < 0.001). Ferritin, soluble CD25 (sCD25), triglycerides (TGs), and ultrasonic spleen longitude, and thickness were all decreased significantly 2 and 4 weeks after the L-DEP regimen (P < 0.001). Thus, the L-DEP regimen is an effective initial therapy for EBV-HLH. However, the L-DEP regimen was poor in terms of long-term prognosis and that allo-HSCT should be received as soon as possible once a complete response is achieved.
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Affiliation(s)
- Leilei Chen
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing (100050), China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing (100050), China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing (100050), China.
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Pi Y, Wang J, Wang Z. Successful Treatment of Relapsed Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis After Allo-HSCT with PD-1 Blockade: A Case Report. Infect Drug Resist 2022; 15:3751-3756. [PMID: 35859915 PMCID: PMC9289273 DOI: 10.2147/idr.s372998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Epstein–Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH) is a rare and aggressive disease with high mortality and poor prognosis. To date, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only way to cure EBV-HLH. However, relapse of EBV-HLH after allo-HSCT is common and remains a major challenge. Case Presentation A 22-year-old woman with persistent fever for a month presented to our center with EBV-HLH. After induction of remission using two cycles of the L-DEP (PEG-aspargase, liposomal doxorubicin, etoposide, and high-dose methylprednisolone) regimen, the patient underwent an human leukocyte antigen (HLA)-identical sibling allo-HSCT. However, she experienced disease relapse soon after the procedure, and none of the possible treatment options achieved a sustained response. Finally, she received a sintilimab injection and achieved complete resolution of EBV-HLH. Conclusion We summarize a case of relapsed EBV-HLH after allo-HSCT that was successfully treated with a programmed cell death protein-1 (PD-1) antibody. Further studies are needed to determine whether PD-1 blockade has therapeutic potential for relapsed EBV-HLH after allo-HSCT.
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Affiliation(s)
- Yubo Pi
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
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Pi Y, Wang J, Zhou H, Ye X, Sun X, Liu L, Pan X, Wang Z. Modified DEP regimen as induction therapy for lymphoma-associated hemophagocytic lymphohistiocytosis: a prospective, multicenter study. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04157-0. [PMID: 35852619 DOI: 10.1007/s00432-022-04157-0] [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: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Hemophagocytic lymphohistiocytosis (HLH), especially lymphoma-associated HLH (LA-HLH), is a refractory immune disorder with high mortality. There is still no consensus regarding the ideal treatment for LA-HLH. METHODS We performed a prospective multicenter study (NCT04077905) to explore the efficacy of a modified DEP regimen as induction therapy for LA-HLH. Twenty-eight patients from 6 clinical centers in China were enrolled between September 2019 and July 2021. We evaluated the efficacy of the modified DEP induction therapy 4 weeks after the initiation of treatment. RESULTS The results showed that the overall response rate was 89.3% (25/28 patients), whereby 28.6% (8/28 patients) achieved a complete response and 60.7% (17/28 patients) were in partial response. Ferritin and soluble CD25 levels were decreased significantly 4 weeks after the modified DEP induction therapy (P = 0.001 and P = 0.00016, respectively), while platelet count and total bilirubin improved significantly (P = 0.004 and P = 0.001, respectively). The 1-year overall survival rate of all patients was 34.5%, with a median survival of 6.5 months (range 0.5-19 months). Patients with LA-HLH who underwent a stem cell transplantation had a significantly better prognosis than those not achieving complete response 4 weeks after modified DEP induction therapy (P = 0.034). CONCLUSION Our study suggests that the modified DEP regimen is a safe and effective induction therapy for LA-HLH. Timely stem cell transplantation can improve the prognosis of patients with LA-HLH. TRAIL REGISTRY NUMBER NCT04077905. URL: https://clinicaltrials.gov/ct2/show/NCT04077905?id=NCT04077905&draw=2&rank=1 .
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Affiliation(s)
- Yubo Pi
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Hui Zhou
- Department of Lymphoma and Hematology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiuhua Sun
- Department of Medical Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ligen Liu
- Department of Hematology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xueyi Pan
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China.
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Shen Z, Jin Y, Sun Q, Zhang S, Chen X, Hu L, He C, Wang Y, Liu Q, Zhang H, Liu X, Wang L, Jiao J, Miao Y, Gu W, Wang F, Wang C, Shi Y, Ye J, Zhu T, Sun C, Song X, Xu L, Yan D, Sun H, Cao J, Li D, Li Z, Wang Z, Huang S, Xu K, Sang W. A Novel Prognostic Index Model for Adult Hemophagocytic Lymphohistiocytosis: A Multicenter Retrospective Analysis in China. Front Immunol 2022; 13:829878. [PMID: 35251016 PMCID: PMC8894441 DOI: 10.3389/fimmu.2022.829878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune disorder with rapid progression and poor survival. Individual treatment strategy is restricted, due to the absence of precise stratification criteria. In this multicenter retrospective study, we aimed to develop a feasible prognostic model for adult HLH in China. A total of 270 newly diagnosed patients of adult HLH were retrieved from the Huaihai Lymphoma Working Group (HHLWG), of whom 184 from 5 medical centers served as derivation cohort, and 86 cases from 3 other centers served as validation cohort. X-Tile program and Maxstat analysis were used to identify optimal cutoff points of continuous variables; univariate and multivariate Cox analyses were used for variable selection, and the Kaplan–Meier curve was used to analyze the value of variables on prognosis. The C-index, Brier Score, and calibration curve were used for model validation. Multivariate analysis showed that age, creatinine, albumin, platelet, lymphocyte ratio, and alanine aminotransferase were independent prognostic factors. By rounding up the hazard ratios from 6 significant variables, a maximum of 9 points was assigned. The final scoring model of HHLWG-HPI was identified with four risk groups: low risk (≤3 pts), low-intermediate risk (4 pts), high-intermediate risk (5-6 pts), and high risk (≥7 pts), with 5-year overall survival rates of 68.5%, 35.2%, 21.3%, and 10.8%, respectively. The C-indexes were 0.796 and 0.758 in the derivation and validation cohorts by using a bootstrap resampling program. In conclusion, the HHLWG-HPI model provides a feasible and accurate stratification system for individualized treatment strategy in adult HLH.
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Affiliation(s)
- Ziyuan Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Yingliang Jin
- Center for Medical Statistics and Data Analysis, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Qian Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shuo Zhang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xi Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Lingling Hu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Chenlu He
- Department of Epidemiology and Biostatistics, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Ying Wang
- Department of Personnel, Suqian First Hospital, Suqian, China
| | - Qinhua Liu
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hao Zhang
- Department of Hematology, The Affiliated Hospital of Jining Medical University, Jining, China
| | - Xin Liu
- Department of Hematology, The Affiliated Hospital of Jining Medical University, Jining, China
| | - Ling Wang
- Department of Hematology, Taian Central Hospital, Taian, China
| | - Jun Jiao
- Department of Hematology, Taian Central Hospital, Taian, China
| | - Yuqing Miao
- Department of Hematology, Yancheng First People’s Hospital, Yancheng, China
| | - Weiying Gu
- Department of Hematology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Fei Wang
- Department of Hematology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Chunling Wang
- Department of Hematology, Huai’an First People’s Hospital, Huai’an, China
| | - Yuye Shi
- Department of Hematology, Huai’an First People’s Hospital, Huai’an, China
| | - Jingjing Ye
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Taigang Zhu
- Department of Hematology, The General Hospital of Wanbei Coal-Electric Group, Suzhou, China
| | - Cai Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xuguang Song
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Linyan Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Dongmei Yan
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Haiying Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiang Cao
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Depeng Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenyu Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuiping Huang
- Center for Medical Statistics and Data Analysis, School of Public Health, Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Sang, ; Kailin Xu, ; Shuiping Huang,
| | - Kailin Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Sang, ; Kailin Xu, ; Shuiping Huang,
| | - Wei Sang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Sang, ; Kailin Xu, ; Shuiping Huang,
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[Characteristic and prognosis of patients with non-EBV infection-associated hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:128-133. [PMID: 35381673 PMCID: PMC8980650 DOI: 10.3760/cma.j.issn.0253-2727.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective: To explore the clinical characteristics and outcomes of patients with non-Epstein-Barr virus (EBV) infection-associated hemophagocytic lymphohistiocytosis (IAHLH) . Methods: Clinical data of 48 patients diagnosed with non-EBV IAHLH in Beijing Friendship Hospital from January 2015 to March 2021 were collected, and the clinical characteristics, treatment, curative effect and prognosis of the patients were analyzed retrospectively. Results: This study included 48 patients, 28 males and 20 females, with a median (range) age of 34.5 (2-74) years. Pathogens that cause IAHLH were as follows: virus (16 cases, 33.3%) , bacteria (17 cases, 35.4%) , parasitic agents (13 cases, 27.1%) , and fungi (2 cases, 4.2%) . The median time from onset to diagnosis of hemophagocytic syndrome (HLH) was 40 (10-160) days. The median (range) time duration from prodrome to the definite diagnosis of IAHLH was 67 (23-270) days. The clinical characteristics were fever (48 cases, 100%) , splenomegaly (34 cases, 70.8%) , cytopenia (38 cases, 79.1%) , elevated ferritin (45 cases, 93.8%) , elevated fasting triglyceride levels (7 cases, 14.6%) , hypofibrinogenemia (17 cases, 35.4%) , decrease natural killer cell activity (26 in 44 cases, 59.1%) , and elevated sCD25 (35 cases, 74.5%) . Twenty-five patients (52.1%) had adenopathy. Once a certain pathogen was identified as the causative factor of hemophagocytic lymphohistiocytosis (HLH) , cytotoxic agents and glucocorticoids were withdrawn, and specific pathogen-directed treatment was initiated. After treatment, 36 cases (75.0%) achieved complete response, and 14 of 15 patients (93.3%) with parasitic and fungal HLH got a response; however, the response rate of patient with bacterial and viral HLH was only 66.7% (22 of 33 patients) . The estimated 5-year overall survival rate was 72.3% (95%CI 50.3%-69.8%) . The adverse prognostic factors were total bilirubin over the upper limit of normal (OR=20.0, 95%CI 1.1-378.3, P=0.046) and pathogenic infection not fully controlled (OR=19.9, 95%CI 2.9-134.5, P=0.002) . Conclusion: Non-EBV IAHLH has a good prognosis. When diagnosed, cytotoxic agents and glucocorticoids should be tapered off, and pathogen-targeted therapy should be critically administered to clear the triggering infection.
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Cheng CN, Chu WY, Chang KC, Chen JS. Lymphoma-based therapy for refractory or relapsed Epstein–Barr virus–related hemophagocytic lymphohistiocytosis in children. J Formos Med Assoc 2022; 121:2351-2355. [DOI: 10.1016/j.jfma.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
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Zhang J, He B, Wang J, Ying C, Zeng L, Zheng S. Differential Diagnosis of Hemophagocytic Syndrome by 18F-FDG PET/CT: A Meta-Analysis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4448993. [PMID: 35132359 PMCID: PMC8817876 DOI: 10.1155/2022/4448993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/23/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022]
Abstract
Hemophagocytic syndrome (HPS) is a rare disease in clinical practice, and there are often cases of delayed diagnosis. At present, researchers have applied 18F-FDG PET/CT in the differential diagnosis of HPS, but no consensus has been formed. Therefore, this study aims to systematically evaluate the application value of 18F-FDG PET/CT in the diagnosis of HPS patients. PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Wangfang database (Wangfang), and Chinese Biomedical Network (CBM) were searched to collect the relevant studies of 18F-FDG PET/CT in the diagnosis of HPS. Data from the articles were screened and extracted for meta-analysis using Stata16.0 software. A total of 10 retrospective studies, including 300 patients, were included in this meta-analysis. The meta-analysis results showed that the pooled sensitivity was 0.82 (95% CI: 0.67-0.95), specificity was 0.72 (95% CI: 0.51-0.86), positive likelihood ratio was 2.89 (95% CI: 1.46-5.75), positive likelihood ratio was 0.25 (95% CI: 0.12-0.54), diagnostic odds ratio was 2.89 (95% CI: 1.46-5.75), and AUC was 0.84 (95% CI: 0.81-0.87). The SUVmax in the liver, spleen, lymph nodes, and bone marrow of HPS patients was greater than 2.5, and the SUVmax in the spleen, lymph nodes, and bone marrow of malignant HPS patients was higher than that of benign HPS patients. The difference was statistically significant (P < 0.05). According to the existing literature evidence, 18F-FDG PET/CT is an effective method for diagnosing HPS.
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Affiliation(s)
- Jun Zhang
- Department of Neurology, Chengdu Xindu District People's Hospital, Chengdu, Sichuan, China
| | - Bang He
- Department of Neurology, Chengdu Xindu District People's Hospital, Chengdu, Sichuan, China
| | - Jian Wang
- Department of Nuclear Medicine Sir Run Run Shaw Hospital School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Caiyun Ying
- Department of Radiology, The First People's Hospital of Chongqing Liang Jiang New Area, Chongqing, China
| | - Lingfeng Zeng
- Department of Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shiyi Zheng
- Department of Radiology, The First People's Hospital of Chongqing Liang Jiang New Area, Chongqing, China
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You Y, Wang J, Wang Z. Programmed death 1 monoclonal antibody helped to treat mixed chimeric and reactivation of Epstein-Barr virus in a patient with adult-onset chronic active Epstein-Barr virus infection after allogeneic hematopoietic stem cell transplantation: A case report. Medicine (Baltimore) 2022; 101:e28542. [PMID: 35029211 PMCID: PMC8758036 DOI: 10.1097/md.0000000000028542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/21/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Systemic forms of chronic active Epstein-Barr virus infection (CAEBV) can predispose a patient to a protracted course of fulminant hemophagocytic lymphohistiocytosis, which has a poor prognosis. Epstein-Barr virus (EBV) infection may persist even after theoretically curative hematopoietic stem cell transplantation. PATIENT CONCERNS A female patient with CAEBV underwent chemotherapy followed by allogeneic hematopoietic stem cell transplantation from her human leukocyte antigen-matched sister. Neutrophil and platelet engraftment was observed on day +12 and +10. Full donor chimerism (DC) was achieved on Day +21. DIAGNOSES From day +38, EBV-DNA in the blood was persistently positive, and DC declined. We attempted empirical interventions such as withdrawal of immune suppression, multiple donor lymphocyte infusion, stem cell boost, and interferon-α treatment. However, EBV-DNA copies continued to increase aggressively, whereas DC decreased rapidly and then reached a nadir of 63.27%. INTERVENTIONS Salvage programmed death 1 (PD-1) antibody treatment was administered as salvage therapy at +69 and +84. OUTCOMES EBV-DNA was negative on day +97 and was ultimately undetectable. Equivalently, a full and stable DC was obtained at +97. LESSONS We summarize a case of PD-1 antibody used as salvage treatment in a post-transplant patient with CAEBV, which was eradicated and full DC was obtained. This case suggests that the PD-1 antibody appears to be a promising option for fighting EBV and mixed DCs.
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Wu D, Bao F, Huang Y. Mucosa-associated lymphoid tissue lymphoma-induced hemophagocytic lymphohistiocytosis: A case report. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221137488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Mucosa-associated lymphoid tissue (MALT) lymphoma-induced hemophagocytic lymphohistiocytosis (HLH) has rarely been reported. Herein, we report the diagnosis and treatment process of a patient with MALT lymphoma-induced HLH who received chemotherapy after diagnosis and finally achieved partial remission. In this case, blood cells were only reduced to grade II at the time of diagnosis, and the patient was then treated with the R-CHOP regimen (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone). HLH responded well to treatment. Laboratory data indicative of HLH and blood chemistry results were steadily normalized, and hepatosplenomegaly resolved. One month after chemotherapy, the patient achieved partial remission. The results also showed that the treatment was successful. In conclusion, treatment of lymphoma-triggered HLH needs to balance HLH-specific and lymphoma-specific treatment. Once HLH is initially controlled or the decrease in blood cells is better than grade II, it should actively transition to lymphoma treatment.
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Affiliation(s)
- Dan Wu
- Department of Hematology and Oncology, The Second People’s Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Fang Bao
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yong Huang
- Department of Hematology and Oncology, The Second People’s Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
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Eichenauer DA, Lachmann G, La Rosée P. Die hämophagozytische Lymphohistiozytose bei kritisch kranken Patienten. WIENER KLINISCHES MAGAZIN 2021; 24:246-251. [PMID: 34697559 PMCID: PMC8529362 DOI: 10.1007/s00740-021-00414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Bei der hämophagozytischen Lymphohistiozytose (HLH) handelt es sich um ein Hyperinflammationssyndrom bedingt durch aberrant aktivierte Makrophagen und T‑Zellen. Beim Erwachsenen ist in erster Linie die erworbene Form anzutreffen. Häufige Auslöser sind Infektionen, Malignome und Autoimmunerkrankungen. Zuletzt wurden zudem zunehmend Fälle berichtet, in denen das Auftreten im Zusammenhang mit stattgehabten Immuntherapien zu sehen war. Auf der Intensivstation ist die HLH aufgrund des ähnlichen klinischen Erscheinungsbilds oft schwer von der Sepsis abzugrenzen. Zum Teil liegen beide zeitgleich vor. Die frühzeitige Diagnosestellung und Einleitung einer adäquaten immunsuppressiven Therapie ist für den weiteren Verlauf und die Prognose der HLH essenziell. Deshalb muss bei kritisch kranken Patienten mit persistierendem Fieber und entsprechenden Symptomen (z. B. Splenomegalie, neurologische Auffälligkeiten) oder Laborveränderungen (z. B. erhöhter Ferritinwert, Zytopenie von 2 oder 3 Zellreihen, erhöhte Transaminasen) das Vorliegen einer HLH in Betracht gezogen werden. Die Diagnose wird mithilfe der HLH-2004-Kriterien gestellt. Mit dem HScore kann die Wahrscheinlichkeit des Vorliegens einer HLH berechnet werden. Hochdosierte Kortikosteroide stellen den Grundpfeiler der HLH-Therapie dar. Je nach Auslöser werden Etoposid, Immunglobuline, Anakinra oder weitere Medikamente ergänzt. Der Verlauf hängt neben einem frühzeitigen Behandlungsbeginn vom Auslöser sowie dem Ansprechen auf die Therapie ab. Insgesamt ist die Prognose der HLH trotz maximaler intensivmedizinischer Behandlung ungünstig und sie ist mit einer hohen Letalität assoziiert.
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Affiliation(s)
- Dennis A. Eichenauer
- Klinik I für Innere Medizin, Zentrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf, Uniklinik Köln, Kerpener Str. 62, 50937 Köln, Deutschland
| | - Gunnar Lachmann
- Klinik für Anästhesiologie mit Schwerpunkt Operative Intensivmedizin, Charité – Universitätsmedizin Berlin, Berlin, Deutschland
| | - Paul La Rosée
- Klinik für Innere Medizin II, Schwarzwald-Baar-Klinikum, Villingen-Schwenningen, Deutschland
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Han HJ, Hong KT, Park HJ, Kim BK, An HY, Choi JY, Kang HJ. Hemophagocytic Lymphohistiocytosis as Initial Presentation of Malignancy in Pediatric Patients: Rare but Not to Be Ignored. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121083. [PMID: 34943279 PMCID: PMC8699877 DOI: 10.3390/children8121083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
It is complicated to establish a consensus on the management and diagnosis of malignancy-triggered hemophagocytic lymphohistiocytosis (M-HLH) in children, as an initial presentation of malignancy is complicated. In this paper, we analyze the clinical characteristics and outcomes of eight pediatric patients in which M-HLH was the initial presentation of malignancy. All patients had hematologic malignancies: three subcutaneous panniculitis-like T-cell lymphomas, two acute lymphoblastic leukemias, two anaplastic large cell lymphomas, and a systemic EBV + T-cell lymphoma of childhood. The incidence rate of M-HLH among leukemia and malignant lymphoma patients in our institution was 1.9%. From the initial diagnosis of HLH, the median time taken to be diagnosed as a malignancy was about 1.3 months. The majority of patients received HLH-targeted immunosuppression and/or etoposide at first. The patients' clinical response to treatment for HLH and malignancies were varied. Five out of the eight patients died, one of whom died due to HLH-related cerebral edema after the initiation of chemotherapy. The median overall survival was 1.6 years. In order to improve the survival rate, the early detection of M-HLH, rapid screening for malignancy, and complete control of M-HLH with HLH-directed therapy followed by a thorough response monitoring are required.
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Affiliation(s)
- Hye-ji Han
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
| | - Kyung Taek Hong
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hyun Jin Park
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Bo Kyung Kim
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hong Yul An
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Jung Yoon Choi
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hyoung Jin Kang
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
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Yang Y, Luo Z, Yuan T. Familial hemophagocytic lymphohistiocytosis in a neonate: Case report and literature review. Medicine (Baltimore) 2021; 100:e27786. [PMID: 34964741 PMCID: PMC8615344 DOI: 10.1097/md.0000000000027786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/29/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Familial hemophagocytic lymphohistiocytosis (FHL) is a potentially fatal disease that rarely presents in the neonatal period. Timely diagnosis is a key challenge owing to the atypical clinical manifestations. Here, we describe a case of FHL type 3 with disease onset in the early neonatal period and review the relevant literature. Our findings may provide insights into the diagnosis and treatment of this rare disease. PATIENT CONCERNS A 6-day-old male neonate presented with fever, hepatosplenomegaly, cytopenia, hyperferritinemia, hypofibrinogenemia, hemophagocytosis, and hypertriglyceridemia. DIAGNOSIS Considering the clinical picture (prolonged fever, progressive hepatosplenomegaly, high triglycerides, low fibrinogen, and high ferritin), along with abnormal natural killer-cell activity, combining sequence analysis of genomic DNA results (compound heterozygous mutations of UNC13D), the patient was finally diagnosed with FHL type 3 (FHL3). INTERVENTIONS The patient was initially treated with HLH-1994 protocol and subsequently switched to an oral regimen of ruxolitinib due to incomplete remission of the disease. OUTCOMES The trend of change in weekly cytokine levels, neutrophil counts, hemoglobin, and platelet counts indicated that the complete remission was not achieved after the treatment of HLH-1994 protocol. The platelet counts fluctuated within the normal range after oral administration of ruxolitinib. But soon after, the patient did not respond to treatment and eventually died of respiratory failure. LESSON Timely diagnosis of FHL is challenging. This case report illustrates that thrombocytopenia can be the first clinical sign of FHL with neonatal onset. Genetic testing, detection of cytokines, and flow cytometry should be performed as soon as possible to confirm the diagnosis. Given the high morbidity and mortality of FHL, pediatricians should have a high suspicion index for this disease.
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Affiliation(s)
- Yue Yang
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, China
| | - Zebin Luo
- Department of Hematology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, China
| | - Tianming Yuan
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, China
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Song Y, Yin Q, Wang J, Wang Z. Autologous Hematopoietic Stem Cell Transplantation for Patients with Lymphoma-Associated Hemophagocytic lymphohistiocytosis. Cell Transplant 2021; 30:9636897211057077. [PMID: 34743574 PMCID: PMC8579341 DOI: 10.1177/09636897211057077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a severe or even fatal inflammatory status. Lymphoma associated hemophagocytic lymphohistiocytosis (LAHS) is a kind of secondary HLH (sHLH). It suffers the worst outcome among sHLH. Allo-HSCT is often considered necessary. Autologous stem cell transplantation (auto-SCT) is widely used in the treatment of lymphoma, especially for high-risk NHL. There have been no clinical reports on the use of auto-SCT in LAHS in the past 20 years. METHODS We retrospectively evaluated 12 LAHS patients who received auto-SCT at our center from January 2013 to January 2020. Follow-up started at the date of LAHS diagnosis and ended at the date of death or last examination. Overall survival (OS) was calculated from the diagnosis of HLH to death of any cause. RESULTS The median period between diagnosis and auto-SCT is 6.7 months. All 12 patients achieved remission after transplantation. Follow-up to 1 January 2021, 8 patients remained disease-free, 4 patients relapsed and 2 of them died eventually. The median follow-up time is 20.9 months, and the median overall survival time has not been reached yet. The 3-year OS rates was 71%. Compared with LAHS patients who did not undergo transplantation during the same period (median OS time is 3.4 months), patients who underwent auto-SCT had a significantly better prognosis (P=0.001). Even if the lymphoma reaches CR after treatment, auto-SCT still provides a better prognosis compared to CR patients without transplantation (P=0.037). Compared with lymphoma patients without HLH who underwent auto-SCT during the same period, they had a similar prognosis (P=0.350). CONCLUSION LAHS, as a common type in secondary HLH, may have a better prognosis after removing the trigger of HLH. In this study, the autologous transplantation in LAHS can significantly improve the prognosis, and provide LAHS a similar prognosis as high-risk lymphoma without HLH.
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Affiliation(s)
- Yue Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qingxia Yin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Song Y, Wang J, Wang Y, Wu L, Wang Z. Requirement for containing etoposide in the initial treatment of lymphoma associated hemophagocytic lymphohistiocytosis. Cancer Biol Ther 2021; 22:598-606. [PMID: 34724875 DOI: 10.1080/15384047.2021.1996139] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe or even fatal inflammatory status caused by a hereditary or acquired immunoregulatory abnormality. Lymphoma-associated hemophagocytic lymphohistiocytosis (LAHS) is a kind of secondary HLH (sHLH). It suffers the worst outcome among sHLH. However, there is no standard treatment strategy. The argument mainly focuses on whether an HLH-directed or malignancy-directed approach should initially be adopted. Etoposide is one of the key drugs in HLH treatment and also shows activity in lymphomas. We sought to identify the importance of containing etoposide in the initial treatment of LAHS. 66 patients diagnosed with LAHS in our center during the three years were divided into two groups according to whether the initial treatment involved etoposide or lymphoma-directed chemotherapy without etoposide. The remission rate of the initial etoposide group (52 patients) is significantly better than that of the no initial etoposide group (14 patients) (73.1% vs. 42.9%, p = .033). The two-month survival rate (79.8% vs. 46.8%, p = .035) and overall survival (median survival time 25.8 w vs. 7.8 w, p = .048) of the initial etoposide contained group is significantly better. Multivariate cox analysis revealed that for patients without EBV infection (37 cases), initial treatment with etoposide could significantly improve prognosis (p = .010, Exp(B) = 0.183), but for patients with positive EBV, it shows a tendency. Containing etoposide is beneficial in the initial treatment of LAHS, whether in the HLH-directed or lymphoma-directed strategy. It provides higher response rate, lower mortality rate, and better survival, especially for EBV negative patients.
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Affiliation(s)
- Yue Song
- Department and Institution: Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingshi Wang
- Department and Institution: Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department and Institution: Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Wu
- Department and Institution: Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department and Institution: Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Hu X, Yang Y, Chen L, Wan Y, Sheng L, Bao Y, Zheng M. Chronic active Epstein-Barr virus infection progresses to aggressive NK cell leukemia with a poor prognosis. Am J Transl Res 2021; 13:12006-12015. [PMID: 34786135 PMCID: PMC8581868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/16/2021] [Indexed: 06/13/2023]
Abstract
Epstein-Barr virus (EBV) associated T/NK-cell lymphoproliferative diseases (EBV-T/NK-LPDs) are a cluster of diseases that include chronic active EBV infection (CAEBV) and aggressive NK cell leukemia (ANKL). The pathogenesis of EBV-T/NK-LPDs is largely unclear and the treatment is difficult and in most cases a hematopoietic stem cell transplantation is needed. Hemophagocytic lymphohistiocytosis (HLH) is known to affect the prognosis of patients with EBV-T/NK-LPDs. This study reports a case of a 20-year-old male patient with repeated infectious mononucleosis (IM)-like symptoms such as high fever, splenomegaly, lymphadenopathy for more than two years. The patient had a high EBV-DNA load (NK cells were the main target cells). He was first diagnosed as CAEBV. However, the disease gradually progressed and the patient developed with high ferritin, phagocytosis and monoclonal NK cells in bone marrow, pancytopenia, increased cytokines, and elevated expression of Ki-67. Also, his NK cells had abnormal immunophenotypes and impaired function. The patient had a typical clinical course of progression from CAEBV to ANKL, accompanied by HLH complications and a poor prognosis. Herein, the detailed diagnostic and differential diagnostic process of EBV infection was shown in this report.
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Affiliation(s)
- Xiangrong Hu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
| | - Yang Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
| | - Liting Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
| | - Yuling Wan
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
| | - Lingshuang Sheng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
| | - Yuhan Bao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
| | - Miao Zheng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, China
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Shen ZY, He CL, Sun Q, Zhang S, Hu LL, Liu QH, Zhang H, Liu X, Miao YQ, Gu WY, Wang F, Wang CL, Shi YY, Wang L, Jiao J, Ye JJ, Xu LY, Yan DM, Li ZY, Jin YL, Huang SP, Xu KL, Sang W. [Clinical prognostic analysis of 124 adult patients with hemophagocytic lymphohistiocytosis: a multicenter retrospective study of the Huaihai Lymphoma Working Group]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:800-806. [PMID: 34788918 PMCID: PMC8607015 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Indexed: 12/31/2022]
Abstract
Objective: Factors influencing the prognosis of hemophagocytic lymphohistiocytosis (HLH) in adults were analyzed based on multicentric data. Methods: Clinical data of 124 adult patients with HLH diagnosed in eight medical centers in the Huaihai Lymphoma Working Group from March 2014 to July 2020 were collected. The optimal truncation value of continuous variables was obtained based on the Maxstat algorithm, X-Tile software, and restricted cubic spline. Cox proportional risk regression model was used to construct the adult HLH risk prediction model, and the visualization of the model was realized through the histogram. The bootstrap resampling method was used to verify the model, C-index and calibration curve was used to verify the histogram, and the prediction accuracy was checked. Kaplan-Meier analysis was used to calculate the survival rate and draw the survival curve. Furthermore, the differences between groups were tested by log-rank. Results: The median age of the 124 patients was 55 (18-84) years, including 61 (49.19%) males. The most common etiology was infection. Serum ferritin increased in 110 cases (88.71%) , hepatosplenomegaly in 57 cases (45.97%) . Of the 124 patients, 77 (62.10%) died, and the median survival time of the patients was 7.07 months. Univariate results showed that the prognosis of adult HLH was influenced by sex, age, fibrinogen, serum creatinine, alanine aminotransferase, and albumin (P<0.05) . The results of multivariate analysis showed that gender, platelet, albumin, alanine aminotransferase, and treatment regimens were independent influencing factors for prognosis. Based on the above five risk factors, the prediction model of the histogram was established, and the C-index of the model was 0.739. Finally, the calibration chart showed good consistency between the observed and predicted values of HLH. Conclusion: The prognosis of the adult hemophagocytic syndrome is influenced by many factors. Gender, platelet, albumin, alanine aminotransferase, and treatment regimens are independent risk factors. Therefore, the established histogram provides a visual tool for clinicians to evaluate the prognosis of adult HLH.
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Affiliation(s)
- Z Y Shen
- Department of Epidemiology and Health Statistics, School of Public Health, Xuzhou Medical University, Xuzhou 221004, China
| | - C L He
- Department of Epidemiology and Health Statistics, School of Public Health, Xuzhou Medical University, Xuzhou 221004, China
| | - Q Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - S Zhang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - L L Hu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - Q H Liu
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - H Zhang
- Department of Hematology, The Affiliated Hospital of Jining Medical University, Jining 272000, China
| | - X Liu
- Department of Hematology, The Affiliated Hospital of Jining Medical University, Jining 272000, China
| | - Y Q Miao
- Department of Hematology, Yancheng First People's Hospital, Yancheng 224001, China
| | - W Y Gu
- Department of Hematology, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - F Wang
- Department of Hematology, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - C L Wang
- Department of Hematology, The First People's Hospital of Huaian, Huaian 223300, China
| | - Y Y Shi
- Department of Hematology, The First People's Hospital of Huaian, Huaian 223300, China
| | - L Wang
- Department of Hematology, Taian Central Hospital, Taian 271000, China
| | - J Jiao
- Department of Hematology, Taian Central Hospital, Taian 271000, China
| | - J J Ye
- Department ofHematology, Qilu Hospital of Shandong University, Jinan 250012, China
| | - L Y Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - D M Yan
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - Z Y Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - Y L Jin
- Department of Epidemiology and Health Statistics, School of Public Health, Xuzhou Medical University, Xuzhou 221004, China
| | - S P Huang
- Department of Epidemiology and Health Statistics, School of Public Health, Xuzhou Medical University, Xuzhou 221004, China
| | - K L Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - W Sang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH), an uncontrolled overactivation of the immune system, is well characterized in pediatric patients, yet, much less is known about this life-threatening condition in adult patients. As HLH is often complicated by organ failure, patients will require admission to the intensive care unit for organ support therapy. However, recognition of HLH patients in the intensive care unit (ICU) is challenged by the clinical overlap with sepsis. Here, we analyze HLH patients to better understand its clinical presentation, diagnosis, and treatment. METHODS For the purpose of this retrospective observational study, we searched for suspected and diagnosed adult HLH of all patients admitted to at least one adult surgical, anesthesiological or medical ICU between January 2006 and August 2018 at the university hospital Charité - Universitätsmedizin Berlin. All cases were reviewed by two HLH experts, who confirmed or declined the diagnosis. RESULTS Of 6,340 ICU patients with ferritin measurement, 40 suffered from HLH (0.63%). Of these, in-hospital mortality was 60.0% over all cases, which was highest in malignancy-associated HLH (71.4%). Infections were identified as most common triggers (42.5%). A variety of 19 different treatment strategies were applied. Non-survivors showed higher ferritin at diagnosis compared with survivors (P = 0.021), which was also seen in multivariable analyses. A minimum ferritin of 4083 μg/L after diagnosis was most predictive for 30-day mortality (AUC 0.888, 95% CI 0.771-1.000; sensitivity 93.8%, specificity 78.9%). CONCLUSIONS Mortality in adult HLH patients in the ICU is high, particularly in malignancy-associated HLH. Infections are the most frequent HLH triggers in critically ill patients. At present, there is no standardized treatment for HLH in adult patients available. Assessment of ferritin is valuable for diagnosis, prognosis, and treatment monitoring. TRIAL REGISTRATION The study was registered with www.ClinicalTrials.gov (NCT02854943) on August 1, 2016.
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Treatment and Mortality of Hemophagocytic Lymphohistiocytosis in Adult Critically Ill Patients: A Systematic Review With Pooled Analysis. Crit Care Med 2021; 48:e1137-e1146. [PMID: 32947471 DOI: 10.1097/ccm.0000000000004581] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis is a cytokine release syndrome caused by uncontrolled immune activation resulting in multiple organ failure and death. In this systematic review, we aimed to analyze triggers, various treatment modalities, and mortality in critically ill adult hemophagocytic lymphohistiocytosis patients. DATA SOURCES MEDLINE database (PubMed) at October 20, 2019. STUDY SELECTION Studies and case series of patients greater than or equal to 18 years old, of whom at least one had to be diagnosed with hemophagocytic lymphohistiocytosis and admitted to an ICU. DATA EXTRACTION Source data of studies and case series were summarized and analyzed on an individual basis. Multivariable logistic regression analysis was performed adjusting for age, sex, and trigger groups. Each single treatment agent was entered as a dichotomous variable to determine treatments associated with survival, regardless if given alone or in combination. DATA SYNTHESIS In total, 661 patients from 65 studies and case series were included. Overall mortality was 57.8%. Infections were the most frequent trigger (49.9%), followed by malignancies (28.0%), autoimmune diseases (12.1%), unknown triggers (9.4%), and drugs (0.6%). Treatment with IV immunoglobulins was associated with improved survival (odds ratio, 0.548; 95% CI, 0.337-0.891; p = 0.015), while treatment with cyclosporine was associated with increased risk of death (odds ratio, 7.571; 95% CI, 3.702-15.483; p < 0.001). Considering different trigger groups separately, same results occurred only for infection-triggered hemophagocytic lymphohistiocytosis. No information was available on disease severity and other confounding factors. CONCLUSIONS Mortality of hemophagocytic lymphohistiocytosis in the ICU is high. Most common triggers were infections. Results of survival analyses may be biased by treatment indication and disease severity. Future studies prospectively investigating treatment tailored to critically ill hemophagocytic lymphohistiocytosis patients are highly warranted.
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Epstein-Barr virus infection is an important cause of hemophagocytic lymphohistiocytosis during chemotherapy for lymphoma. Infect Dis Now 2021; 51:310-311. [PMID: 33934811 DOI: 10.1016/j.idnow.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/04/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022]
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Li Z, Liu J, Man Y, Liu F, Gao L, Hu P, Zhao R, Wang Y, Yang T. Analysis of cytokine risk factors in the early death of patients with secondary phagocytic lymphocytic histiocytosis. Am J Transl Res 2021; 13:2388-2398. [PMID: 34017397 PMCID: PMC8129357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/25/2021] [Indexed: 06/12/2023]
Abstract
Secondary hemophagocytic lymphohistiocytosis (sHLH) is an excessive inflammatory response syndrome caused by immune abnormalities. Up to date, the risk factors for cytokines causing early death in sHLH patients have not been elucidated. Our study reviewed the cytokine expression levels in peripheral blood of 50 sHLH patients. Through Cox proportional hazard model analysis, we found that IL-17F ≥2.835 pg/mL (HR = 5.922, 95% CI = 1.793-19.558, P = 0.004) was an independent death risk factor in sHLH patients, and it was also 30 days (Cutoff-value = 2.890 pg/mL, HR = 16.568, 95% CI = 1.917-143.195, P = 0.011), 60 days (Cutoff-value = 2.890 pg/mL, HR = 7.559, 95% CI = 1.449-39.423, P = 0.016), 90 day death risk factor (Cutoff-value = 2.835 pg/mL, HR = 7.649, 95% CI = 1.965-29.778, P = 0.003); IL-10 ≥16.730 pg/mL (HR = 4.821, 95% CI = 1.151-20.116, P = 0.031) is not only a death risk factor within 90 days, but also within 10 days (Cutoff-value = 944.350 pg/mL, HR = 13.321, 95% CI = 1.123-158.03, P = 0.027); and IL-5 ≥2.495 pg/mL (HR = 15.687, 95% CI = 1.377-178.645, P = 0.04) was also a death risk factor within 10 days. Besides, IL-17F, IL-10, IL-5, and the previously reported common risk factors Age, platelets, activated partial thromboplastin time, triglyceride, and lactate dehydrogenase were analyzed together. It was found that the patient age ≥56 years-old is was an important risk factor for death within 30 days, IL-17 ≥2.89 pg/mL and IL-10 ≥16.73 pg/mL are important risk factors for patient death. In summary, our data indicate that age, IL-10 and IL-17F are important risk factors for early death in sHLH patients.
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Affiliation(s)
- Zengzheng Li
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Jianqiong Liu
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Yan Man
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
| | - Fusheng Liu
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
| | - Lili Gao
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Peng Hu
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Renbin Zhao
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Yajie Wang
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
| | - Tonghua Yang
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
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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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You Y, Wang J, Wang Y, Wei N, Wu L, Chen L, Song D, Wang Z. Non-EBV infection-associated hemophagocytic lymphohistiocytosis: a distinct subgroup where pathogen-directed therapy is essential and favorable outcomes are expected. Leuk Lymphoma 2021; 62:1657-1663. [PMID: 33586592 DOI: 10.1080/10428194.2021.1885657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
EBV is the most prevalent cause of infection-associated hemophagocytic lymphohistiocytosis (IAHLH), non-EBV IAHLH is observed clinically but less documented. We conducted a retrospective research enrolled 36 cases from 1/1/2015 to 31/12/2019. Intriguingly, 92% cases were immunocompetent individuals prior to the onset of HLH. Clinically, the cardinal features were prolonged high fever, splenomegaly and hemophagocytosis. Bicytopenia occurred in most patients, besides, liver dysfunction was characterized by increased transaminase, bilirubin, alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (γ-GGT) and lactate dehydrogenase (LDH). Immunomodulatory agents should be added to control the overwhelming inflammatory storm without delay. Once a certain pathogen was identified as the causative factor of HLH, cytotoxic agents were withdrawn, specific pathogen-directed treatment was initiated. Further, glucocorticoids were tapered off when a stable state of HLH was achieved. After treatment, about 70% patients were fully recovered without relapse. All in all, non-EBV IAHLH is a special group of HLH with admirable outcome.
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Affiliation(s)
- Yahong You
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Na Wei
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Wu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Leilei Chen
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Deli Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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[Hemophagocytic lymphohistiocytosis in critically ill patients]. Med Klin Intensivmed Notfmed 2021; 116:129-134. [PMID: 33580314 PMCID: PMC7880632 DOI: 10.1007/s00063-021-00781-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/25/2020] [Accepted: 01/08/2021] [Indexed: 12/30/2022]
Abstract
Bei der hämophagozytischen Lymphohistiozytose (HLH) handelt es sich um ein Hyperinflammationssyndrom bedingt durch aberrant aktivierte Makrophagen und T‑Zellen. Beim Erwachsenen ist in erster Linie die erworbene Form anzutreffen. Häufige Auslöser sind Infektionen, Malignome und Autoimmunerkrankungen. Zuletzt wurden zudem zunehmend Fälle berichtet, in denen das Auftreten im Zusammenhang mit stattgehabten Immuntherapien zu sehen war. Auf der Intensivstation ist die HLH aufgrund des ähnlichen klinischen Erscheinungsbilds oft schwer von der Sepsis abzugrenzen. Zum Teil liegen beide zeitgleich vor. Die frühzeitige Diagnosestellung und Einleitung einer adäquaten immunsuppressiven Therapie ist für den weiteren Verlauf und die Prognose der HLH essenziell. Deshalb muss bei kritisch kranken Patienten mit persistierendem Fieber und entsprechenden Symptomen (z. B. Splenomegalie, neurologische Auffälligkeiten) oder Laborveränderungen (z. B. erhöhter Ferritinwert, Zytopenie von 2 oder 3 Zellreihen, erhöhte Transaminasen) das Vorliegen einer HLH in Betracht gezogen werden. Die Diagnose wird mithilfe der HLH-2004-Kriterien gestellt. Mit dem HScore kann die Wahrscheinlichkeit des Vorliegens einer HLH berechnet werden. Hochdosierte Kortikosteroide stellen den Grundpfeiler der HLH-Therapie dar. Je nach Auslöser werden Etoposid, Immunglobuline, Anakinra oder weitere Medikamente ergänzt. Der Verlauf hängt neben einem frühzeitigen Behandlungsbeginn vom Auslöser sowie dem Ansprechen auf die Therapie ab. Insgesamt ist die Prognose der HLH trotz maximaler intensivmedizinischer Behandlung ungünstig und sie ist mit einer hohen Letalität assoziiert.
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Wang J, Zhang R, Wu X, Li F, Yang H, Liu L, Guo H, Zhang X, Mai H, Li H, Wang Z. Ruxolitinib-combined doxorubicin-etoposide-methylprednisolone regimen as a salvage therapy for refractory/relapsed haemophagocytic lymphohistiocytosis: a single-arm, multicentre, phase 2 trial. Br J Haematol 2021; 193:761-768. [PMID: 33559893 DOI: 10.1111/bjh.17331] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/23/2020] [Indexed: 02/02/2023]
Abstract
We performed a multicentre, non-randomised trial (NCT03533790) to investigate the efficacy of ruxolitinib combined with the doxorubicin-etoposide-methylprednisolone (Ru-DEP) regimen as a salvage therapy for refractory/relapsed haemophagocytic lymphohistiocytosis (HLH). All patients failing to achieve a complete or partial response 2 weeks after initial HLH-94/HLH-04 regimen or relapsed after remission were enrolled in the study between June 2018 and June 2019. The efficacy was evaluated 2 weeks after initiating Ru-DEP salvage therapy. Fifty-four eligible patients with refractory/relapsed (R/R) HLH were enrolled. One case could not be evaluated for efficacy. Excluding 12 patients who had previously received the DEP regimen, the overall response rate was 32 of 41 (78·0%) patients, with eight of 41 (19·5%) achieving complete response and 24 of 41 (58·5%) attaining a partial response. Of the R/R HLH patients who had previously received the DEP regimen, 7 of 12 (58·3%) achieved a partial response. Ferritin and soluble CD25 concentrations were significantly lower (P < 0·05), while the platelet count increased significantly (P = 0·034), and triglycerides decreased significantly (P = 0·002) compared with those before treatment. The Ru-DEP regimen may be a safe and effective salvage therapy, remaining effective in refractory/relapsed HLH following DEP treatment, especially in macrophage activation syndrome. In addition, the regimen can be considered for patients with contraindications to glucocorticoid, especially those with gastrointestinal bleeding.
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Affiliation(s)
- Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Rui Zhang
- Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University Of Science And Technology, Hubei, China
| | - Fei Li
- Department of Hematology, The First Affiliated Hospital Of Nanchang University, Jiangxi, China
| | - Haixia Yang
- Department of Hematology, Hunan Children's Hospital, Hunan, China
| | - Ligen Liu
- Department of Hematology, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haixia Guo
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangdong, China
| | - Xuejun Zhang
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei, China
| | - Huirong Mai
- Department of Hematology-Oncology, Shenzhen Children's Hospital, Guangdong, China
| | - Hui Li
- Department of Hematology-Oncology, Wuhan Women and Children medical care center, Hubei, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Zheng XQ, Zhu HY, Wang JY, Fan L, Xu W, Li J. [Research progress of lymphoma associated hemophagocytic syndrome]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:788-792. [PMID: 33113618 PMCID: PMC7595859 DOI: 10.3760/cma.j.issn.0253-2727.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- X Q Zheng
- Department of Hematology, Key Laboratory of Hematology of Nanjing Medical University, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - H Y Zhu
- Department of Hematology, Key Laboratory of Hematology of Nanjing Medical University, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China; Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
| | | | | | | | - Jianyong Li
- Department of Hematology, Key Laboratory of Hematology of Nanjing Medical University, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China; Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
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Li B, Guo J, Li T, Gu J, Zeng C, Xiao M, Zhang W, Li Q, Zhou J, Zhou X. Clinical Characteristics of Hemophagocytic Lymphohistiocytosis Associated with Non-Hodgkin B-Cell Lymphoma: A Multicenter Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:e198-e205. [PMID: 33303420 DOI: 10.1016/j.clml.2020.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/17/2020] [Accepted: 10/19/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) associated with B-cell lymphoma is a highly aggressive disease with unclear clinical features and has no standard treatment. PATIENTS AND METHODS We analyzed the clinical characteristics of 31 patients from two individual centers. RESULTS The median overall survival was only 1.5 months. Both univariate and multivariate analyses, based on lymphoma or HLH-related characteristics, revealed that patients with high Epstein-Barr virus (EBV) DNA load and ≥ 2 extranodal lesions, or hypofibrinogenemia, respectively, showed significantly poorer overall survival. Interestingly, some patients with high EBV DNA load had EBV-positive natural killer (NK) and/or T cells, which may be related to the coexistence of immunodeficiency and/or chronic active EBV infection. Molecular genetics examination confirmed that 47.4% (9/19) of patients had complex karyotypes, 37.5% (3/8) of patients had TP53 deletions, and 21.34% (3/14) of patients had TP53 mutation or alteration of malignancy-related pathways, including BCR/NF-κB, JAK-STAT, and epigenetic regulatory pathways, which may provide clues to choose targets for therapy. Treatment regimens containing etoposide, anti-CD20 monoclonal antibodies, or anthracyclines improved patient prognosis (P = .0183, .025, and .0436, respectively). Patients with infections had significantly shorter survival than those without infections (P = .00019). CONCLUSION The patients' performance status, number of extranodal lesions, high EBV DNA load, and hypofibrinogenemia are poor prognostic factors for HLH associated with B-cell lymphoma. Molecular genetic high-risk factors are of particular importance because these factors can provide information for prognosis prediction, treatment decisions, and disease surveillance.
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Affiliation(s)
- Baihua Li
- Department of Hematology, YiChang Central People's Hospital, The First College of Clinical Medical Science, China Three Gorges University, Yichang, China
| | - Jingming Guo
- Department of Hematology, YiChang Central People's Hospital, The First College of Clinical Medical Science, China Three Gorges University, Yichang, China
| | - Tongjuan Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Gu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chen Zeng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qinlu Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxi Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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