Survival in primary hemophagocytic lymphohistiocytosis, 2016 to 2021: etoposide is better than its reputation

Clinical Characteristics and Treatment of Familial Hemophagocytic Lymphohistiocytosis

Familial hemophagocytic lymphohistiocytosis (fHLH) comprises a group of autosomal recessive disorders characterized by germline loss-of-function variants that negatively impact lymphocyte cytotoxicity. These disorders exhibit variable clinical presentations, most often in association with severe hyperinflammation. fHLH is diagnosed through clinical and laboratory assessments as well as genetic testing and immunologic assays. In the absence of therapy to control the hyperactive immune system, fHLH is generally fatal. Treatment has historically taken the form of cytotoxic chemotherapy and/or immunosuppressive therapy, although targeted inhibitors of inflammatory cytokines and their downstream signaling are increasingly being utilized. Definitive treatment requires allogeneic hematopoietic cell transplantation.

Assessing the effectiveness of etoposide treatment in adult haemophagocytic lymphohistiocytosis: a systematic review and meta-analysis

Haemophagocytic lymphohistiocytosis (HLH) is a serious condition characterised by uncontrolled hyperinflammation. Etoposide has been used as a treatment option in paediatric HLH; however, its effectiveness and the necessity for adult induction therapy remain unclear. This systematic review and meta-analysis aimed to assess the effectiveness of etoposide-based induction therapy in adult HLH, focusing on overall response (OR). A systematic literature search was conducted to identify relevant studies on 11 December 2023, resulting in the inclusion of seven studies in the analysis. The pooled data demonstrated a significant improvement in OR with etoposide-based therapy in adult patients with HLH (1.95, 95% CI 1.51-2.53), compared with non-etoposide-treated patients. Furthermore, overall survival improved with etoposide treatment (1.25, 95% CI 1.03-1.52). Our analysis revealed the potential benefit of etoposide-based therapy in adult patients with HLH. Therefore, etoposide should be considered as a timely and early therapeutic option for the management of adult HLH.

Thrombocytopenia in Critically Ill Children: A Review for Practicing Clinicians

Thrombocytopenia frequently occurs in patients before, during, and after admission to Pediatric Intensive Care Units (PICUs). In critically ill children, it is often due to multifactorial causes and can be a sign of significant organ dysfunction. This review summarizes the potential causes/mechanisms of thrombocytopenia in acutely ill children, their identification, and treatments, with special attention paid to septic patients. The mechanisms of thrombocytopenia include decreased production and sequestration, but the most common reason is increased destruction or consumption. This review specifically reviews and compares the presentation, pathogenesis, and treatment of disseminated intravascular coagulation (DIC) and the thrombotic microangiopathic spectrum (TMA), including thrombocytopenia-associated multiorgan failure (TAMOF), hemolytic uremic syndrome, and other diagnoses. The other etiologies discussed include HLH/MAS, immune thrombocytopenia, and dilutional thrombocytopenia. Finally, this review analyzes platelet transfusions, the various thresholds, and complications.

Goodbye etoposide? Taking the leap to ruxolitinib in haemophagocytic lymphohistiocytosis

Fang et al. report a retrospective analysis of paediatric patients with haemophagocytic lymphohistiocytosis (HLH) associated with autoimmune/autoinflammatory disorders treated with ruxolitinib. Responses were impressive and rapid, and ruxolitinib was well tolerated. This study demonstrates that a subset of patients with HLH can be treated with JAK inhibition without the need for cytotoxic chemotherapy. Further work will be needed to better define patient selection for therapy, as some patient groups and HLH triggers, such as malignancy-associated HLH, may be better suited for etoposide-based therapy. Commentary on: Fang et al. Ruxolitinib-based regimen in children with autoimmune disease or autoinflammatory disease related hemophagocytic lymphohistiocytosis. Br J Haematol 2025; 206:215-223.

HCT in the widening spectrum of congenital immunodeficiencies

PURPOSE OF REVIEW

Hematopoietic stem cell transplantation (HSCT) and inborn errors of immunity (IEI) have been closely linked since transplantation was first used to cure severe combined immunodeficiency (SCID) in 1968. Since then, novel genes and diseases have been continually added to the ongoing list of IEI, and new data on indications and outcomes have emerged. We review recent data and progress in the field of hematopoietic cell transplantation (HCT) for IEI including new diseases and complications.

RECENT FINDINGS

Emerging data from haploidentical transplants, newborn screening results, and multicentric studies reveals promising outcomes for IEI. Immune dysregulation diseases deserve special attention regarding disease control and may require additional drugs pretransplant. Female carriers of X-linked Chronic granulomatous may present with a severe phenotype warranting the need for HCT. Insights from infectious complications and long-term comorbidities should help guide decisions to treat IEI patients.

SUMMARY

From classical indications to recently described diseases, HCT for immunodeficiencies is a rapidly growing field. Novel data regarding alternative donor transplants, results from large cohorts, and long-term complications provide valuable knowledge for clinical practice.

Ruxolitinib-based regimen in children with autoimmune disease or autoinflammatory disease-related haemophagocytic lymphohistiocytosis

For autoimmune disease (AD) and autoinflammatory disease (AID)-related haemophagocytic lymphohistiocytosis (HLH) (AD/AID-HLH), there is still a lack of standardized treatment. Glucocorticoids (GCs) are the main treatment currently; however, 37.9% to 61% of patients fail to achieve effective control of HLH, making it urgent to find novel treatment strategies. We conducted a retrospective, single-centre study examining ruxolitinib (RUX)-based regimen in children with AD/AID-HLH. Patients were first treated with RUX monotherapy, and additional treatments including methylprednisolone and etoposide were added sequentially when the disease could not be controlled. The study included 26 patients with a median follow-up of 23.9 months, of whom 15 had prior treatments. The overall response rate at week 8 with the RUX-based regimen was 96.2%, with 92.3% attaining complete response (CR) and 3.9% attaining partial response. The 2-year overall survival rate was 96.2% (95% CI, 80.4% to 99.9%). During RUX monotherapy, 46.1% of patients achieved CR as the best response, with a median first response time to RUX of 2 days. Additionally, 53.8% of patients required additional GCs and 23.1% required etoposide chemotherapy. All observed adverse events were manageable and acceptable. Overall, our study supports the efficacy and safety of the RUX-based regimen in children with AD/AID-HLH.

COX Regression Analysis and Mortality Risk Prediction Model of 85 Adult Patients with Secondary Hemophagocytic Lymphohistiocytosis

Aims/Background Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare, rapidly progressive and highly lethal disease. This retrospective cohort study aims to analyze the factors influencing the mortality risk in adult patients with sHLH, which are instrumental to improving our understanding of the high mortality risks associated with sHLH. Methods This study included 85 patients diagnosed with sHLH who were admitted and treated in the Department of Emergency, Peking University People's Hospital between April 2015 and July 2023. Participants were classified based on prognosis into two groups: the death group and the survival group. We collected demographic data, routine blood tests, comprehensive biochemical profiles, coagulation analyses, serum ferritin levels, natural killer (NK) cell counts, soluble interleukin-2 receptor (sCD25) levels, and potential etiological factors upon admission. The mortality risk factors influencing the prognosis of sHLH were analyzed with univariate and multivariate COX regression. Additionally, a mortality risk prediction model was established, and its accuracy was validated and optimized using the concordance index (C-index), time-dependent receiver operating characteristic (ROC) curve, calibration curves and clinical decision curve analysis (DCA). Results A total of 85 patients were included in this study, the male-to-female ratio is 1:1.4. The median age at diagnosis of sHLH was 56.00 (33.00-69.00) years. Clinical symptoms were atypical, with fever being the most prevalent symptom (81 cases, 95.3%), followed by disturbance of consciousness (10 cases, 11.8%). Univariate COX analysis and Multivariate COX regression analysis revealed that age (hazard ratio (HR) [95% confidence interval (CI)], 1.098 [1.025-1.177], p = 0.008), Alanine transaminase (ALT) (HR [95% CI], 1.016 [1.001-1.031], p = 0.034), Aspartate transaminase (AST) (HR [95% CI], 1.005 [1.001-1.008], p = 0.004), and Troponin I (TNI) levels (HR [95% CI], 1.196 [1.011-1.414], p = 0.037) were independent risk factors affecting prognosis. Specifically, sHLH patients aged ≥63.5 years (sensitivity 82.8%, specificity 85.7%), with AST levels ≥111 U/L (sensitivity 82.8%, specificity 82.1%), ALT ≥41 U/L (sensitivity 58.6%, specificity 64.3%) and TNI levels ≥2.15 ng/mL (sensitivity 62.1%, specificity 100%), faced a higher risk of mortality. We established a mortality risk prediction model for sHLH patients, which yielded a C-index of 0.848 (0.773-0.901), indicating strong agreement between predicted and observed outcomes. The ROC curves of the 28-day, 60-day, and 90-day mortality risk prediction model for sHLH patients were drawn, and the results showed that the 28-day, 60-day, and 90-day area under the curve (AUC) were 0.900 (0.829-0.971), 0.940 (0.882-0.998), and 0.930 (0.874-0.986), respectively. The predictive effect of the prediction model is satisfactory. Additionally, the clinical decision curve analysis for 28, 60 and 90 days in sHLH patients indicated that the net benefit of the nomogram model was higher than that line of extremes models (treat all and treat none). Conclusion Patients with sHLH have frequently atypical clinical presentation, with early death risk and notably elevated mortality rate. Independent risk factors influencing mortality risk in sHLH patients include age ≥63.5 years, AST ≥111 U/L, ALT ≥41 U/L, and TNI ≥2.15 ng/mL. With high accuracy and efficacy, the risk prediction model constructed can facilitate timely identification of sHLH patients at elevated risk of mortality, which is critical for optimizing clinical interventions.

SARS-CoV-2 reactivates fungal-associated Hemophagocytic lymphohistiocytosis: Case report and review of the literature

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease characterized by the uncontrolled activation of the immune system, resulting in a high clinical mortality rate. A 56-year-old Chinese female presented at the emergency room with symptoms including fever, fatigue, nausea, vomiting, cough, shortness of breath, and chest tightness. Laboratory investigations demonstrated decreased levels of white blood cells, hemoglobin, and platelets while interleukin-6 and ferritin exhibited significant elevations. She was subsequently admitted to the hematology department, where she was diagnosed with HLH caused by a Candida infection. Following treatment with antifungal agents, glucocorticoids, antiemetics, diuretics, and hepatoprotective therapy, the patient's condition has shown improvement. However, after being infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the patient experienced a reactivation of HLH, resulting in a more severe clinical presentation and complications compared to the initial onset. Although the patient's condition improved after the administration of antiviral drugs, etoposide, glucocorticoids, cyclosporin, and intravenous immunoglobulin, this case highlights the possibility of disease reactivation during the recovery phase of HLH. This should raise the attention of medical professionals.

Reactive hemophagocytic lymphohistiocytosis: Epidemiological, clinico-biological and etiological profile

Hemophagocytic lymphohistiocytosis (HLH) is an hyperinflammatory state resulting from increased secretion of proinflammatory cytokines, which are responsible for clinical, biological and cytological manifestations.

OBJECTIVE

The aim of our study is to describe the epidemiological, clinical, biological, etiological and evolutionary profile of HLH in Tunisia.

METHODS

A retrospective study that involved patients, with images of hemophagocytosis in myelograms analyzed at the laboratory of biological hematology of the University Hospital "Hédi-Chaker" of Sfax-Tunisia, followed at these departments: hematology, internal medicine, department of infectious-diseases and department of gastroenterology, (June2017- May2021). First, we identified all patients with hemophagocytosis images. Secondly, we selected the patients who fulfilled the diagnostic criteria of the HLH-2004-score.

RESULTS

Nineteen patients were included in this study. Nine men and 10 women with a mean age of 37.95 years. Fever was present in all patients. Organomegaly was described in 74% of cases. The most frequent cytopenia was anemia (100%). Hypertriglyceridemia was noted in 79% of cases and hyperferritinemia (> 500 ng/mL) was ubiquitous. In myelogram, 68% of patients had slides showing numerous or very numerous images of hemophagocytosis. The infectious pathology was the most common cause of HLH (42%). No cause was found in 10% of cases. The corticosteroid therapy at a dose of 1 mg/kg/day was prescribed in 89% of our patients. The overall evolution was favorable in 58% of cases. The mortality was not associated with the causal pathology (p=0.218).

CONCLUSION

Secondary HLH is likely to be under-recognized, which contributes to its high morbidity and mortality. Early recognition is crucial for any reasonable attempt at curative therapy.

Transplantation for immune dysregulatory disorders: current themes and future expectations

PURPOSE OF REVIEW

Primary immune regulatory disorders (PIRDs) are an increasing indication for hematopoietic stem cell transplant (HCT) in pediatric patients. Here, we provide an updated overview of HCT for PIRDs, and discuss future avenues for improvement in outcomes.

RECENT FINDINGS

There are now more than 50 described monogenic PIRDs, which impact all aspects of immune tolerance, regulation, and suppression. Disease characteristics are highly variable, and HCT remains the only option for cure. We review advances in targeted therapies for individual PIRDs, which have significantly improved outcomes and the ability to safely bridge to transplant. Additionally, advances in GVHD prevention, graft manipulation, personalized conditioning regimens, and supportive care have all increased survival after HCT. The high inflammatory state increases the risk of nonengraftment, rejection, and autologous reconstitution. Therapy to reduce the inflammatory state may further improve outcomes. In addition, although younger patients with fewer comorbidities have better outcomes, the clinical courses of these diseases may be extremely variable thereby complicating the decision to proceed to HCT.

SUMMARY

HCT for PIRDs is a growing consideration in cell therapy. Yet, there remain significant gaps in our understanding of which patients this curative therapy could benefit the most. Here, we review the current data supporting HCT for PIRDs as well as areas for future improvement.

Hyaluronic acid-functionalized carboxymethyl dextran-coated melatonin nanoconjugates for targeted etoposide delivery in metastatic colon cancer: Extensive in-vitro investigation in HCT116 cell lines, antimicrobial efficacy, and anti-angiogenic potential in chick chorioallantoic membrane (CAM) assay

Managing advanced colon cancer is challenging, requiring targeted therapies. This study presents a novel nanoconjugate system, HA-CMD@ETP-MLT-NCs, designed to deliver etoposide (ETP) specifically to colon cancer cells. The system consists of Hyaluronic Acid (HA)-Functionalized Carboxymethyl Dextran (CMD) coated with Melatonin (MLT). The nanoconjugates showed good stability, with a zeta potential of -29.90 mV and a particle size of 199.1 nm. They achieved an 80.3 % yield and a high drug entrapment efficiency of 93.4 %. In vitro release studies demonstrated pH-dependent drug release, with 73.4 % released at pH 5.5 (tumour-like environment) and 42.6 % at pH 7.4 (normal tissue) over 24 h. The nanoconjugates improved cellular uptake, induced apoptosis, and reduced reactive oxygen species (ROS) in HCT116 colon cancer cells. Flow cytometry showed a significant decrease in ROS levels, and lipid peroxidation inhibition increased to 56.67 %. These findings suggest that HA-CMD@ETP-MLT-NCs enhance etoposide delivery and reduce side effects. Further in vivo studies and clinical trials are needed to confirm its therapeutic potential.

Association of busulfan exposure and outcomes after HCT for patients with an inborn error of immunity

ABSTRACT

Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative treatment strategy for patients with inborn errors of immunities (IEIs). The objective of this study was to assess the optimal busulfan exposure before allogeneic HCT for patients with an IEI who received an IV busulfan-based conditioning regimen. Patients from 17 international centers were included. The main outcome of interest was event-free survival (EFS). Patients were categorized into 4 IEI subgroups: combined immunodeficiency (CID), severe combined immunodeficiency (SCID), neutrophil disorders, and hemophagocytic lymphohistiocytosis (HLH)-related disorders. Busulfan exposure was calculated by individual centers (area under the curve [AUC]CENTER) and re-estimated using a nonlinear mixed-effects model (NONMEM; exposure defined as AUCNONMEM). Overall, 562 patients were included: 173 (30.8%) with CID, 154 (27.4%) with SCID, 101 (18.0%) with HLH-related disorders, and 134 (23.8%) with neutrophil disorders. The median busulfan AUCNONMEM was 69.0 mg × h/L and correlated poorly with the AUCCENTER (r2 = 0.54). In patients with SCID, HLH-related, and neutrophil disorders with a busulfan AUCNONMEM of 70 to 90 mg × h/L, 2-year EFS was superior to <70 mg × h/L, and >90 mg ×h/L. Full donor chimerism increased with higher busulfan AUCNONMEM, plateauing at 90 mg × h/L. For patients with CID, the optimal AUCNONMEM for donor chimerism was found to be >70 mg × h/L. Improved EFS and higher donor chimerism may be achieved by targeting a cumulative busulfan AUCNONMEM of 80 mg × h/L (range, 70-90). Our study stresses the importance of uniformly using a validated population pharmacokinetic model to estimate AUCNONMEM.

Improved survival outcomes with anakinra over etoposide-based therapies for the management of adults with hemophagocytic lymphohistiocytosis: a retrospective multicenter research network study

Background

Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening, hyperinflammatory syndrome for which etoposide-based regimens have historically been the standard of care. Recent reports have described positive outcomes with the utilization of ruxolitinib or anakinra although these studies are often limited to small samples.

Objectives

We aimed to compare the efficacy of ruxolitinib, anakinra, and etoposide-based therapies for the management of HLH in adult patients.

Design

We performed a population-based, multicenter, retrospective cohort study utilizing the TriNetX Networks database.

Methods

Adult patients (⩾18 years) diagnosed with HLH who received first-line treatment with ruxolitinib, anakinra, or etoposide between 2008 and 2023 were analyzed. The primary endpoint was overall survival (OS) at 1 year. A 1:1 propensity-score matching analysis was utilized.

Results

Anakinra (p = 0.020) but not ruxolitinib (p = 0.19) resulted in a significantly higher 1-year OS when compared with etoposide-based therapies.

Conclusions

Anakinra is effective for the management of adult patients with HLH.