1
|
Akiyama D, Kanda J, Hanyu Y, Amagase H, Kondo T, Miyamoto T, Yasumi T, Yoshinaga N, Takaori-Kondo A. Successful Second CBT for Graft Failure After First CBT for Adult-Onset Familial Hemophagocytic Lymphohistiocytosis Type 3: A Case Report. Transplant Proc 2024:S0041-1345(24)00277-X. [PMID: 38811303 DOI: 10.1016/j.transproceed.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/10/2024] [Indexed: 05/31/2024]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is a rare inherited autosomal recessive immune deficiency that usually manifests during infancy or early childhood, rarely occurring in adults. Hematopoietic stem cell transplantation (HSCT) is the only curative treatment for FHL. However, optimal conditioning regimens for adult-onset FHL have not yet been established. Herein, we report a case of adult-onset FHL. A 37-year-old man presented with fever, liver dysfunction, and pancytopenia, which improved temporarily with corticosteroid therapy. However, he later developed encephalitis and myelitis. Genetic analysis revealed rare variants of UNC13D (c.2367+1 g>a and c.2588 g>a), which were compound heterozygous pathogenic mutations. FHL type 3 was diagnosed, and treatment based on the hemophagocytic lymphohistiocytosis (HLH) 1994 protocol was initiated. The patient underwent cord blood transplantation (CBT) with myeloablative conditioning using fludarabine, melphalan, and total-body irradiation (TBI), which resulted in graft rejection. The patient was successfully rescued by a second CBT following reduced-intensity conditioning with fludarabine, cyclophosphamide, and TBI. Although graft failure is an important complication especially in CBT, it could be managed by appropriate treatment, and that cord blood would be a promising alternative source with the advantages of rapidity and avoidance of related donors with a high risk of harboring the same genetic mutation.
Collapse
Affiliation(s)
- Daisuke Akiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Yuta Hanyu
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Amagase
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takayuki Miyamoto
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
2
|
Ishimura M, Eguchi K, Sonoda M, Tanaka T, Shiraishi A, Sakai Y, Yasumi T, Miyamoto T, Voskoboinik I, Hashimoto K, Matsumoto S, Ozono S, Moritake H, Takada H, Ohga S. Early hematopoietic cell transplantation for familial hemophagocytic lymphohistiocytosis in a regional treatment network in Japan. Int J Hematol 2024; 119:592-602. [PMID: 38507116 DOI: 10.1007/s12185-024-03721-3] [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: 07/10/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 03/22/2024]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHLH) is a fatal hyperinflammation syndrome arising from the genetic defect of perforin-mediated cytolysis. Curative hematopoietic cell transplantation (HCT) is needed before development of central nervous system (CNS) disease. We studied treatment outcomes of 13 patients (FHLH2 n = 11, FHLH3 n = 2) consecutively diagnosed from 2011 to 2022 by flow cytometric screening for non-myeloablative HCT in a regional treatment network in Kyushu, Japan. One patient with a novel PRF1 variant escaped screening, but all patients with FHLH2 reached diagnosis and 8 of them received HCT until 3 and 9 months of age, respectively. The earliest HCT was conducted 65 days after birth. Three pretransplant deaths occurred in newborns with liver failure at diagnosis. Ten posttransplant patients have remained disease-free, 7 of whom had no neurological involvement. Time from first etoposide infusion to HCT was shorter in patients without CNS disease or bleeding than in patients with those factors (median [range] days: 62 [50-81] vs. 122 [89-209], p = 0.016). Six of 9 unrelated patients had a PRF1 c.1090_1091delCT variant. These results suggest that the critical times to start etoposide and HCT are within 3 months after birth and during etoposide control, respectively. Newborn screening may increase the percentage of disease-free survivors without complications.
Collapse
Affiliation(s)
- Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Katsuhide Eguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Motoshi Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tamami Tanaka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Akira Shiraishi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Miyamoto
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ilia Voskoboinik
- Cancer Immunology Program, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kunio Hashimoto
- Department of Pediatrics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Faculty of Life Science, Kumamoto University, Kumamoto, Japan
| | - Shuichi Ozono
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Hiroshi Moritake
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hidetoshi Takada
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| |
Collapse
|
3
|
Kim H, Mizuno K, Masuda K, Sakurai M, Ara T, Naito K, Uehara Y, Yamamoto G, Osada M, Machida S, Horio T, Fukushima K, Mori Y, Ichinohe T, Fukuda T, Atsuta Y, Kataoka K. A Nationwide Retrospective Analysis of Allogeneic Hematopoietic Stem Cell Transplantation for Adult Hemophagocytic Lymphohistiocytosis. Transplant Cell Ther 2024; 30:419.e1-419.e12. [PMID: 38266963 DOI: 10.1016/j.jtct.2024.01.071] [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: 11/15/2023] [Revised: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by systemic hyperinflammation. Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only potentially curative treatment for primary and relapsed/refractory HLH, the optimal strategy has not been established. We retrospectively analyzed 56 adult patients (≥18 years) with primary and secondary HLH (mainly consisting of Epstein-Barr virus-associated HLH) who underwent allo-HSCT using the registry database of the Japanese Society for Transplantation and Cellular Therapy, including 26 patients who underwent cord blood transplantation (CBT). One-fourth of patients received myeloablative conditioning (MAC), mainly consisting of total body irradiation-based regimens. The 3-year overall survival (OS) was 40.6%, while the 3-year cumulative incidences of relapse and non-relapse mortality (NRM) were 19.8% and 39.6%, respectively. In univariable analysis, age at allo-HSCT (the 3-year OS: 27.5% for ≥ 25 years old vs 58.0% for < 25 years old, P = .025), conditioning intensity (7.1% for MAC vs 51.8% for reduced-intensity conditioning (RIC), P = .002), and donor source (26.0% for CBT vs 52.9% for bone marrow or peripheral blood stem cell transplantation (BMT/PBSCT), P = .030) were associated with significantly inferior OS. In multivariable analysis, older age at allo-HSCT (≥ 25 years old) (Hazard ratio [HR], 2.37; 95% CI, 1.01 to 5.58; P = .048), MAC (HR, 2.45; 95% CI, 1.09 to 5.53; P = .031), and CBT (HR, 2.21; 95% CI, 1.04 to 4.71; P = .040) were independently associated with worse OS. In addition, only conditioning intensity predicted higher NRM (the 3-year NRM: 78.6% for MAC vs 26.6% for RIC), while no factors were associated with the relapse rate. This study includes the largest number of adult HLH patients undergoing CBT. Although the use of CBT is acceptable, BMT/PBSCT are more favorable strategies in allo-HSCT in adult HLH. Regarding conditioning intensity, RIC regimens are more beneficial in this setting.
Collapse
Affiliation(s)
- Haryoon Kim
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Molecular Oncology, National Cancer Center Research Institute, Tokyo, Japan
| | - Kota Mizuno
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Molecular Oncology, National Cancer Center Research Institute, Tokyo, Japan
| | - Kyoko Masuda
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masatoshi Sakurai
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Hospital, Sapporo, Japan
| | - Kensuke Naito
- Department of Hematology, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Yasufumi Uehara
- Department of Hematology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Go Yamamoto
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Makoto Osada
- Department of Hematology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shinichiro Machida
- Department of Hematology/Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Tomohiro Horio
- Division of Hematology, Department of Internal Medicine, Aichi Medical University Hospital, Nagakute, Japan
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasuo Mori
- Hematology, Oncology & Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan; Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Keisuke Kataoka
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Molecular Oncology, National Cancer Center Research Institute, Tokyo, Japan.
| |
Collapse
|
4
|
Yue Y, Fan S, Liu Z, Jiang F, Chen J, Qin J, Sun Y. Sequential haplo-identical conditioning transplant regimen for pediatric patients with relapsed or refractory hemophagocytic lymphohistiocytosis. Bone Marrow Transplant 2024; 59:513-517. [PMID: 38287082 DOI: 10.1038/s41409-024-02212-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/31/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) currently stands as the sole remedy for individuals afflicted with hemophagocytic lymphohistiocytosis (HLH). In this study, we retrospectively evaluated how pediatric patients with relapsed or refractory (R/R) HLH responded to our institution's cocktail conditioning regimen. The disease was diagnosed according to criteria applicable to patients with familial/genetic, relapsing, or severe/persistent HLH. All donors were HLA haplo-identical family donors. In our cohort, sixty-five patients (P-HLH), including 28 with familial/genetic HLH, 36 with secondary HLH, and 1 with an unknown cause, underwent haplo-identical family donor HSCT. The conditioning regimen consisted of intravenous administration of etoposide (VP-16), busulfan, fludarabine, rabbit anti-human thymocyte globulin (r-ATG), and cyclophosphamide (Cy). Tacrolimus and mycophenolate mofetil were used for graft-versus-host disease (GvHD) prevention. We observed that the median time for neutrophil recovery was 11 days (range, 8-24), and for platelet counts to exceed 20 × 109/L, it was 14 days (range, 7-130). There were 5 patients (7.7%) who experienced grades III to IV acute GvHD, and 6 patients (9.2%) developed extensive chronic GvHD. The estimated 3- and 5-year overall survival rates were 78.1% (95% CI, 65.8-84.6%) and 74.9% (95% CI, 61.2-84.4%), respectively. The estimated 3- and 5-year event-free survival rates were 73.5% (95% CI, 60.8-82.6%) and 70.3% (95% CI, 56.4-80.5%), respectively. Our findings demonstrate that our innovative conditioning regimen is both effective and safe, offering valuable insights for healthcare professionals evaluating the merits of existing therapies.
Collapse
Affiliation(s)
- Yan Yue
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Shifen Fan
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Zhouyang Liu
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Fan Jiang
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Jiao Chen
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China
| | - Jiayue Qin
- Department of Medical Affairs, Acornmed Biotechnology Co., Ltd., Tianjin, China
| | - Yuan Sun
- Department of Hematology and Oncology, Hospital of Beijing Jingdu Pediatrics, Beijing, China.
| |
Collapse
|
5
|
Böhm S, Wustrau K, Pachlopnik Schmid J, Prader S, Ahlmann M, Yacobovich J, Beier R, Speckmann C, Behnisch W, Ifversen M, Jordan M, Marsh R, Naumann-Bartsch N, Mauz-Körholz C, Hönig M, Schulz A, Malinowska I, Hines M, Nichols KE, Gil-Herrera J, Talano JA, Crooks B, Formankova R, Jorch N, Bakhtiar S, Kühnle I, Streiter M, Nathrath M, Russo A, Dürken M, Lang P, Lindemans C, Henter JI, Lehmberg K, Ehl S. Survival in primary hemophagocytic lymphohistiocytosis, 2016 to 2021: etoposide is better than its reputation. Blood 2024; 143:872-881. [PMID: 37992218 DOI: 10.1182/blood.2023022281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/24/2023] Open
Abstract
ABSTRACT Primary hemophagocytic lymphohistiocytosis (pHLH) is a life-threatening hyperinflammatory syndrome that develops mainly in patients with genetic disorders of lymphocyte cytotoxicity and X-linked lymphoproliferative syndromes. Previous studies with etoposide-based treatment followed by hematopoetic stem cell transplantation (HSCT) resulted in 5-year survival of 50% to 59%. Contemporary data are lacking. We evaluated 88 patients with pHLH documented in the international HLH registry from 2016-2021. In 12 of 88 patients, diagnosis was made without HLH activity, based on siblings or albinism. Major HLH-directed drugs (etoposide, antithymocyte globulin, alemtuzumab, emapalumab, ruxolitinib) were administered to 66 of 76 patients who were symptomatic (86% first-line etoposide); 16 of 57 patients treated with etoposide and 3 of 9 with other first-line treatment received salvage therapy. HSCT was performed in 75 patients; 7 patients died before HSCT. Three-year probability of survival (pSU) was 82% (confidence interval [CI], 72%-88%) for the entire cohort and 77% (CI, 64%-86%) for patients receiving first-line etoposide. Compared with the HLH-2004 study, both pre-HSCT and post-HSCT survival of patients receiving first-line etoposide improved, 83% to 91% and 70% to 88%. Differences to HLH-2004 included preferential use of reduced-toxicity conditioning and reduced time from diagnosis to HSCT (from 148 to 88 days). Three-year pSU was lower with haploidentical (4 of 9 patients [44%]) than with other donors (62 of 66 [94%]; P < .001). Importantly, early HSCT for patients who were asymptomatic resulted in 100% survival, emphasizing the potential benefit of newborn screening. This contemporary standard-of-care study of patients with pHLH reveals that first-line etoposide-based therapy is better than previously reported, providing a benchmark for novel treatment regimes.
Collapse
Affiliation(s)
- Svea Böhm
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
| | - Katharina Wustrau
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Jana Pachlopnik Schmid
- Division of Immunology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Pediatric Immunology, University Children's Hospital Zurich-Eleonorenstiftung, Zürich, Switzerland
| | - Seraina Prader
- Division of Immunology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Pediatric Immunology, University Children's Hospital Zurich-Eleonorenstiftung, Zürich, Switzerland
| | - Martina Ahlmann
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Joanne Yacobovich
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Tel Aviv Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Rita Beier
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Carsten Speckmann
- Division of Pediatric Hematology and Oncology Faculty of Medicine, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Behnisch
- Center for Pediatrics and Adolescent Medicine, Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rebecca Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nora Naumann-Bartsch
- Clinic for Children and Adolescents, University Clinic Erlangen, Erlangen, Germany
| | - Christine Mauz-Körholz
- Pediatric Hematooncology, University Children's Hospital Giessen, Giessen, Germany
- Medical Faculty, Martin-Luther University of Halle-Wittenberg, Halle, Germany
| | - Manfred Hönig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Iwona Malinowska
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Melissa Hines
- Division of Critical Care, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Kim E Nichols
- Division of Critical Care, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Juana Gil-Herrera
- Immunology, Hospital General Universitario and Instituto de Investigación Sanitaria "Gregorio Marañón," Madrid, Spain
| | - Julie-An Talano
- Pediatric Hematology/Oncology/Blood and Marrow Transplant Division, Medical College of Wisconsin, Madison, WI
| | - Bruce Crooks
- Paediatric Haematology/Oncology, IWK Health Centre, Halifax, NS, Canada
| | - Renata Formankova
- Department of Pediatric Haematology and Oncology, University Hospital Motol Prague, Prague, Czech Republic
| | - Norbert Jorch
- Bielefeld University, University Clinic for Pediatrics, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Shahrzad Bakhtiar
- Center for Pediatric and Adolescent Medicine, Frankfurt University Hospital, Frankfurt, Germany
| | - Ingrid Kühnle
- Division of Pediatric Hematology and Oncology, Göttingen University Medical Center, Göttingen, Germany
| | - Monika Streiter
- Clinic for Pediatrics and Adolescent Medicine, Hematology/Oncology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Michaela Nathrath
- Pediatric Hematology and Oncology, Psychosomatics and Systemic Diseases, Kassel Hospital, Kassel, Germany
- Department of Pediatrics and Children's Cancer Research Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexandra Russo
- Center for Pediatric and Adolescent Medicine, Pediatric Hematology/Oncology, University of Mainz, Mainz, Germany
| | - Matthias Dürken
- Department of Pediatrics and Adolescent Medicine, Mannheim University Hospital, Mannheim, Germany
| | - Peter Lang
- Clinic for Children and Adolescents, Department I Hematology/Oncology, Tübingen University Hospital, Tübingen, Germany
| | - Caroline Lindemans
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center, Utrecht, The Netherlands
| | - Jan-Inge Henter
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
6
|
Ge J, Zhang Q, Ma H, Wang D, Zhao Y, Zhu T, Wang W, Zhou C, Wei A, Lian H, Qin M, Yang J, Li Z, Wang T, Zhang R. Ruxolitinib-based regimen in children with primary hemophagocytic lymphohistiocytosis. Haematologica 2024; 109:458-465. [PMID: 37470145 PMCID: PMC10828753 DOI: 10.3324/haematol.2023.283478] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023] Open
Abstract
Primary hemophagocytic lymphohistiocytosis (pHLH) is a rare immune disorder and hematopoietic stem cell transplan- tation (HSCT) is the only potentially curative treatment. Given the high pre-HSCT mortality of pHLH patients reported in the HLH-2004 study (17%), more regimens to effectively control the disease and form a bridge with HSCT are needed. We conducted a retrospective study of pHLH children treated by ruxolitinib (RUX)-based regimen. Generally, patients received RUX until HSCT or unacceptable toxic side-effect. Methylprednisolone and etoposide were added sequentially when the disease was suboptimally controlled. The primary end point was 1-year overall survival. Twenty-one pHLH patients (12 previously treated and 9 previously untreated) were included with a median follow-up of 1.4 years. At last follow-up, 17 (81.0%) patients were alive with a 1-year overall survival of 90.5% (95% confidence interval: 84.1-96.9). Within the first 8 weeks, all patients had an objective response, of which 19 (90.5%) achieved complete response (CR) and two (9.5%) achieved partial response (PR) as a best response. Seventeen (81.0%) patients received HSCT, of which 13 (76.5%) had CR, three (17.6%) had PR and one (5.9%) had disease reactivation at the time of HSCT. Fifteen (88.2) patients were alive post- HSCT. Notably, eight (38.1%) patients received zero doses of etoposide, suggesting the potential of RUX-based regimen to reduce chemotherapy intensity. Patients tolerated RUX-based regimen well and the most frequently observed adverse events were hematologic adverse events. Overall, RUX-based regimen was effective and safe and could be used as a bridge to HSCT for pHLH children.
Collapse
Affiliation(s)
- Jian Ge
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Qing Zhang
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Honghao Ma
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Dong Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Yunze Zhao
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Ting Zhu
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Wenqian Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Chenxin Zhou
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Ang Wei
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Hongyun Lian
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Maoquan Qin
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing
| | - Jun Yang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing
| | - Zhigang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Tianyou Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing
| | - Rui Zhang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Beijing, China; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing.
| |
Collapse
|
7
|
Dettmer-Monaco V, Weißert K, Ammann S, Monaco G, Lei L, Gräßel L, Rhiel M, Rositzka J, Kaufmann MM, Geiger K, Andrieux G, Lao J, Thoulass G, Schell C, Boerries M, Illert AL, Cornu TI, Ehl S, Aichele P, Cathomen T. Gene editing of hematopoietic stem cells restores T-cell response in familial hemophagocytic lymphohistiocytosis. J Allergy Clin Immunol 2024; 153:243-255.e14. [PMID: 37595758 DOI: 10.1016/j.jaci.2023.08.003] [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: 05/07/2023] [Revised: 07/04/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory disorder characterized by a life-threatening cytokine storm and immunopathology. Familial HLH type 3 (FHL3) accounts for approximately 30% of all inborn HLH cases worldwide. It is caused by mutations in the UNC13D gene that result in impaired degranulation of cytotoxic vesicles and hence compromised T-cell- and natural killer-cell-mediated killing. Current treatment protocols, including allogeneic hematopoietic stem cell (HSC) transplantation, still show high mortality. OBJECTIVE We sought to develop and evaluate a curative genome editing strategy in the preclinical FHL3 Jinx mouse model. Jinx mice harbor a cryptic splice donor site in Unc13d intron 26 and develop clinical symptoms of human FHL3 upon infection with lymphocytic choriomeningitis virus (LCMV). METHODS We employed clustered regularly interspaced short palindromic repeats (CRISPR)-Cas technology to delete the disease-causing mutation in HSCs and transplanted Unc13d-edited stem cells into busulfan-conditioned Jinx recipient mice. Safety studies included extensive genotyping and chromosomal aberrations analysis by single targeted linker-mediated PCR sequencing (CAST-Seq)-based off-target analyses. Cure from HLH predisposition was assessed by LCMV infection. RESULTS Hematopoietic cells isolated from transplanted mice revealed efficient gene editing (>95%), polyclonality of the T-cell receptor repertoire, and neither signs of off-target effects nor leukemogenesis. Unc13d transcription levels of edited and wild-type cells were comparable. While LCMV challenge resulted in acute HLH in Jinx mice transplanted with mock-edited HSCs, Jinx mice grafted with Unc13d-edited cells showed rapid virus clearance and protection from HLH. CONCLUSIONS Our study demonstrates that transplantation of CRISPR-Cas edited HSCs supports the development of a functional polyclonal T-cell response in the absence of genotoxicity-associated clonal outgrowth.
Collapse
Affiliation(s)
- Viviane Dettmer-Monaco
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg
| | - Kristoffer Weißert
- Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg
| | - Sandra Ammann
- Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg
| | - Gianni Monaco
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute of Neuropathology, Medical Center-University of Freiburg, Freiburg
| | - Lei Lei
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Ph.D. Program, Faculty of Biology, University of Freiburg, Freiburg
| | - Linda Gräßel
- Department of Internal Medicine I, Medical Center-University of Freiburg, Freiburg; German Cancer Consortium, Partner Site Freiburg & German Cancer Research Center, Heidelberg
| | - Manuel Rhiel
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg
| | - Julia Rositzka
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg
| | - Masako M Kaufmann
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Spemann Graduate School of Biology and Medicine, University of Freiburg, Freiburg
| | - Kerstin Geiger
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Ph.D. Program, Faculty of Biology, University of Freiburg, Freiburg
| | - Geoffroy Andrieux
- Institute of Medical Bioinformatics and Systems Medicine, Medical Center-University of Freiburg, Freiburg; Faculty of Medicine, University of Freiburg, Freiburg
| | - Jessica Lao
- Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Ph.D. Program, Faculty of Biology, University of Freiburg, Freiburg
| | - Gudrun Thoulass
- Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Ph.D. Program, Faculty of Biology, University of Freiburg, Freiburg
| | - Christoph Schell
- Faculty of Medicine, University of Freiburg, Freiburg; Institute of Surgical Pathology, Medical Center-University of Freiburg, Freiburg
| | - Melanie Boerries
- German Cancer Consortium, Partner Site Freiburg & German Cancer Research Center, Heidelberg; Institute of Medical Bioinformatics and Systems Medicine, Medical Center-University of Freiburg, Freiburg; Faculty of Medicine, University of Freiburg, Freiburg
| | - Anna L Illert
- Department of Internal Medicine I, Medical Center-University of Freiburg, Freiburg; German Cancer Consortium, Partner Site Freiburg & German Cancer Research Center, Heidelberg; Faculty of Medicine, University of Freiburg, Freiburg
| | - Tatjana I Cornu
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Faculty of Medicine, University of Freiburg, Freiburg
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Faculty of Medicine, University of Freiburg, Freiburg
| | - Peter Aichele
- Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Institute for Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Faculty of Medicine, University of Freiburg, Freiburg
| | - Toni Cathomen
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg; Center for Chronic Immunodeficiency, Medical Center-University of Freiburg, Freiburg; Faculty of Medicine, University of Freiburg, Freiburg.
| |
Collapse
|
8
|
Yao S, He L, Zhang R, Liu M, Hua Z, Zou H, Wang Z, Wang Y. Improved hemophagocytic lymphohistiocytosis index predicts prognosis of adult Epstein-Barr virus-associated HLH patients. Ann Med 2023; 55:89-100. [PMID: 36533966 PMCID: PMC9766494 DOI: 10.1080/07853890.2022.2149850] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Epstein-Barr virus (EBV)-associated hemophagocytic lymphohistiocytosis (EBV-HLH) is a common subtype of HLH with heterogeneous clinical presentations from self-limited to death, of which adults are worse than children. OBJECTIVE To establish predictors of mortality risk in adult EBV-HLH patients for timely and appropriate treatment. METHODS Patients with confirmed EBV-HLH admitted to Beijing Friendship Hospital from January 2015 to December 2019 were enrolled and statistical analysis of their laboratory test results was performed. RESULTS Among 246 adult patients with EBV-HLH, the deceased were older (p < 0.05), with fewer blood cells (p < 0.05), poorer renal function (p < 0.01), higher levels of procalcitonin (PCT) (p < 0.01), as well as soluble interleukin-2 receptor (sCD25) (p < 0.01). The overall median survival time of patients was 135 days, 87 days for patients without transplantation and 294 days with transplantation (p < 0.001). A combined index of sCD25, PCT, and estimated glomerular filtration rate (eGFR) was obtained to predict prognosis, named the Improved HLH index (IH index), and patients were divided into three groups meeting IH- (i.e. sCD25 ≤ 18,000 pg/mL, PCT ≤ 1.8 ng/mL, eGFR ≥ 90 mL/min/1.73m2), IH1+ (i.e. only sCD25 > 18,000 pg/mL or only eGFR < 90 mL/min/1.73m2), and IH2+ (i.e. the rest), respectively. In patients with the HScore ≥ 169 or meeting HLH-04, those meeting IH2+ had significantly worse prognoses than those who met IH1+ or IH- (p < 0.001). In the group meeting IH + or IH2+, patients who received allo-HSCT had better prognoses than those who did not (p < 0.05), but there was still a significant difference in prognosis among the three groups in transplanted patients (p < 0.001). CONCLUSION The IH index can early identify adult patients with a poor prognosis of EBV-HLH, initiating timely and appropriate treatment.KEY MESSAGESA combined index of sCD25, PCT, and eGFR was obtained to predict prognosis, named the Improved Hemophagocytic Lymphohistiocytosis index (IH index).IH index can early identify adult patients with a poor prognosis of EBV-HLH, initiating timely and appropriate treatment.
Collapse
Affiliation(s)
- Shuyan Yao
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lingbo He
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruoxi Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Menghan Liu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhengjie Hua
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Heshan Zou
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao 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.,Department of General Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
von Asmuth EGJ, Neven B, Albert MH, Mohseny AB, Schilham MW, Binder H, Putter H, Lankester AC. Predicting Patient Death after Allogeneic Stem Cell Transplantation for Inborn Errors Using Machine Learning (PREPAD): A European Society for Blood and Marrow Transplantation Inborn Errors Working Party Study. Transplant Cell Ther 2023; 29:775.e1-775.e8. [PMID: 37709203 DOI: 10.1016/j.jtct.2023.09.007] [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: 08/15/2023] [Accepted: 09/07/2023] [Indexed: 09/16/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for many inborn errors of immunity, metabolism, and hematopoiesis. No predictive models are available for these disorders. We created a machine learning model using XGBoost to predict survival after HSCT using European Society for Blood and Marrow Transplant registry data of 10,888 patients who underwent HSCT for inborn errors between 2006 and 2018, and compared it to a simple linear Cox model, an elastic net Cox model, and a random forest model. The XGBoost model had a cross-validated area under the curve value of .73 at 1 year, which was significantly superior to the other models, and it accurately predicted for countries excluded while training. It predicted close to 0% and >30% mortality more often than other models at 1 year, while maintaining good calibration. The 5-year survival was 94.7% in the 25% of patients at lowest risk and 62.3% in the 25% at highest risk. Within disease and donor subgroups, XGBoost outperformed the best univariate predictor. We visualized the effect of the main predictors-diagnosis, performance score, patient age and donor type-using the SHAP ML explainer and developed a stand-alone application, which can predict using the model and visualize predictions. The risk of mortality after HSCT for inborn errors can be accurately predicted using an explainable machine learning model. This exceeds the performance of models described in the literature. Doing so can help detect deviations from expected survival and improve risk stratification in trials.
Collapse
Affiliation(s)
- Erik G J von Asmuth
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
| | - Bénédicte Neven
- Pediatric Hematology and Immunology Unit, Necker Hospital for Sick Children, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Michael H Albert
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital LMU Munich, Germany
| | - Alexander B Mohseny
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco W Schilham
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C Lankester
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
10
|
Tsilifis C, Slatter MA, Gennery AR. Too much of a good thing: a review of primary immune regulatory disorders. Front Immunol 2023; 14:1279201. [PMID: 38022498 PMCID: PMC10645063 DOI: 10.3389/fimmu.2023.1279201] [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: 08/17/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Primary immune regulatory disorders (PIRDs) are inborn errors of immunity caused by a loss in the regulatory mechanism of the inflammatory or immune response, leading to impaired immunological tolerance or an exuberant inflammatory response to various stimuli due to loss or gain of function mutations. Whilst PIRDs may feature susceptibility to recurrent, severe, or opportunistic infection in their phenotype, this group of syndromes has broadened the spectrum of disease caused by defects in immunity-related genes to include autoimmunity, autoinflammation, lymphoproliferation, malignancy, and allergy; increasing focus on PIRDs has thus redefined the classical 'primary immunodeficiency' as one aspect of an overarching group of inborn errors of immunity. The growing number of genetic defects associated with PIRDs has expanded our understanding of immune tolerance mechanisms and prompted identification of molecular targets for therapy. However, PIRDs remain difficult to recognize due to incomplete penetrance of their diverse phenotype, which may cross organ systems and present to multiple clinical specialists prior to review by an immunologist. Control of immune dysregulation with immunosuppressive therapies must be balanced against the enhanced infective risk posed by the underlying defect and accumulated end-organ damage, posing a challenge to clinicians. Whilst allogeneic hematopoietic stem cell transplantation may correct the underlying immune defect, identification of appropriate patients and timing of transplant is difficult. The relatively recent description of many PIRDs and rarity of individual genetic entities that comprise this group means data on natural history, clinical progression, and treatment are limited, and so international collaboration will be needed to better delineate phenotypes and the impact of existing and potential therapies. This review explores pathophysiology, clinical features, current therapeutic strategies for PIRDs including cellular platforms, and future directions for research.
Collapse
Affiliation(s)
- Christo Tsilifis
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mary A. Slatter
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew R. Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
11
|
Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS). Arthritis Rheumatol 2023; 75:1714-1732. [PMID: 37486733 PMCID: PMC11040593 DOI: 10.1002/art.42636] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
Collapse
Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, NIH, Bethesda, Maryland
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, and Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hines
- Pediatric Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University and Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children’s Hospital, Houston
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward M. Behrens
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Randy Q. Cron
- Pediatric Rheumatology, University of Alabama at Birmingham
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California
| | - Alexei A. Grom
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Lauren A. Henderson
- Pediatric Immunology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annacarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B. Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Kim E. Nichols
- Division of Cancer Predisposition Department of Oncology, St. Jude Children’s Research Hospital Department of Oncology, Memphis, Tennessee
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | | | - Rebecca A. Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Scott W. Canna
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). Ann Rheum Dis 2023; 82:1271-1285. [PMID: 37487610 PMCID: PMC11017727 DOI: 10.1136/ard-2023-224123] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
Collapse
Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa Hines
- Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children's Hospital, Houston, Texas, USA
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California, USA
| | - Alexei A Grom
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren A Henderson
- Pediatric Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Annacarin Horne
- Department of Women's and Children's Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Kim E Nichols
- Division of Cancer Predisposition Department of Oncology, St Jude Children's Research Hospital Department of Oncology, Memphis, Tennessee, USA
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Rebecca A Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Scott W Canna
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
13
|
Bayram C, Tahtakesen TN, Arslantaş E, Yilmaz E, Özdemir GN, Pasli Uysalol E, Gökçe M, Akçay A, Tuğcu D, Ayçiçek A. Prognostic Factors and Long-term Outcomes in 41 Children With Primary Hemophagocytic Lymphohistiocytosis: Report of a Single-center Experience and Review of the Literature. J Pediatr Hematol Oncol 2023; 45:262-266. [PMID: 36898032 DOI: 10.1097/mph.0000000000002653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/28/2023] [Indexed: 03/12/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome with diverse clinical manifestations leading to major diagnostic and therapeutic difficulties. This study aimed to evaluate clinical manifestations, prognostic factors, and long-term outcomes in children with primary HLH. Forty-one patients diagnosed with primary HLH were retrospectively evaluated for patient characteristics, HLH gene mutations, clinical and laboratory manifestations, prognostic factors, and long-term outcomes. The median age of the patients at the time of diagnosis was 3 months (minimum to maximum: 1 to 144 mo). There were 23 patients who had HLH mutation analysis performed, 10 patients with PRF1 mutation, 6 with STX11 mutation, and 7 with UNC13D mutation. Thirteen patients (31.7%) had central nervous system involvement. No correlation was found between overall survival and central nervous system involvement. The estimated 5-year overall survival for the patient who had hematopoietic stem cell transplantation was 9.4 times better than the patients who did not receive hematopoietic stem cell transplantation (81.3% vs 16.7%; P = 0.001). Median serum sodium and blood urea nitrogen levels were significantly higher in deceased HLH patients compared with surviving HLH patients ( P = 0.043, and P = 0.017, respectively). Primary HLH has a poor outcome with high mortality, which necessitates well-designed and international clinical trials to improve diagnosis, therapy, and long-term outcomes.
Collapse
Affiliation(s)
- Cengiz Bayram
- Department of Pediatric Hematology and Oncology, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Hosahalli Vasanna S, Dalal J. Traffic jam within lymphocytes: A clinician's perspective. Front Immunol 2023; 13:1034317. [PMID: 36726976 PMCID: PMC9885010 DOI: 10.3389/fimmu.2022.1034317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
With the discovery of novel diseases and pathways, as well as a new outlook on certain existing diseases, cellular trafficking disorders attract a great deal of interest and focus. Understanding the function of genes and their products in protein and lipid synthesis, cargo sorting, packaging, and delivery has allowed us to appreciate the intricate pathophysiology of these biological processes at the molecular level and the multi-system disease manifestations of these disorders. This article focuses primarily on lymphocyte intracellular trafficking diseases from a clinician's perspective. Familial hemophagocytic lymphohistiocytosis is the prototypical disease of abnormal vesicular transport in the lymphocytes. In this review, we highlight other mechanisms involved in cellular trafficking, including membrane contact sites, autophagy, and abnormalities of cytoskeletal structures affecting the immune cell function, based on a newer classification system, along with management aspects of these conditions.
Collapse
Affiliation(s)
- Smitha Hosahalli Vasanna
- Department of Pediatrics, Division of Pediatric Hematology Oncology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, United States,School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Jignesh Dalal
- Department of Pediatrics, Division of Pediatric Hematology Oncology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, United States,School of Medicine, Case Western Reserve University, Cleveland, OH, United States,*Correspondence: Jignesh Dalal,
| |
Collapse
|
15
|
Weißert K, Ammann S, Kögl T, Dettmer‐Monaco V, Schell C, Cathomen T, Ehl S, Aichele P. Adoptive T cell therapy cures mice from active hemophagocytic lymphohistiocytosis (HLH). EMBO Mol Med 2022; 14:e16085. [PMID: 36278424 PMCID: PMC9728053 DOI: 10.15252/emmm.202216085] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022] Open
Abstract
Primary hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome caused by impaired lymphocyte cytotoxicity. First-line therapeutic regimens directed against activated immune cells or secreted cytokines show limited efficacy since they do not target the underlying immunological problem: defective lymphocyte cytotoxicity causing prolonged immune stimulation. A potential rescue strategy would be the adoptive transfer of ex vivo gene-corrected autologous T cells. However, transfusion of cytotoxicity-competent T cells under conditions of hyperinflammation may cause more harm than benefit. As a proof-of-concept for adoptive T cell therapy (ATCT) under hyperinflammatory conditions, we transferred syngeneic, cytotoxicity-competent T cells into mice with virally triggered active primary HLH. ATCT with functional syngeneic trigger-specific T cells cured Jinx mice from active HLH without life-threatening side effects and protected Perforin-deficient mice from lethal HLH progression by reconstituting cytotoxicity. Cured mice were protected long-term from HLH relapses. A threshold frequency of transferred T cells with functional differentiation was identified as a predictive biomarker for long-term survival. This study is the first proof-of-concept for ATCT in active HLH.
Collapse
Affiliation(s)
- Kristoffer Weißert
- Institute for Immunodeficiency, Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Faculty of BiologyAlbert‐Ludwigs‐University of FreiburgFreiburgGermany
| | - Sandra Ammann
- Institute for Immunodeficiency, Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tamara Kögl
- Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Institute for Immunology, Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Viviane Dettmer‐Monaco
- Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Institute for Transfusion Medicine and Gene Therapy, Medical CenterUniversity of FreiburgFreiburgGermany
| | - Christoph Schell
- Institute of Surgical Pathology, Medical CenterUniversity of FreiburgFreiburgGermany
| | - Toni Cathomen
- Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Institute for Transfusion Medicine and Gene Therapy, Medical CenterUniversity of FreiburgFreiburgGermany
| | - Stephan Ehl
- Institute for Immunodeficiency, Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Center for Integrative Biological Signalling StudiesAlbert‐Ludwigs‐University of FreiburgFreiburgGermany
| | - Peter Aichele
- Institute for Immunodeficiency, Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany,Center for Chronic Immunodeficiency (CCI), Medical Center ‐ University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| |
Collapse
|
16
|
Higuchi T, Izawa K, Miyamoto T, Honda Y, Nishiyama A, Shimizu M, Takita J, Yasumi T. An efficient diagnosis: A patient with X-linked inhibitor of apoptosis protein (XIAP) deficiency in the setting of infantile hemophagocytic lymphohistiocytosis was diagnosed using high serum interleukin-18 combined with common laboratory parameters. Pediatr Blood Cancer 2022; 69:e29606. [PMID: 35187790 DOI: 10.1002/pbc.29606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Toru Higuchi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan.,Department of Pediatrics, Shiga Medical Center for Children, Moriyama, Shiga, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| | - Takayuki Miyamoto
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| | - Yoshitaka Honda
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan.,Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Kyoto City, Kyoto, Japan
| | - Atsuko Nishiyama
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Masaki Shimizu
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junko Takita
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| |
Collapse
|
17
|
Caldirola MS, Raccio AG, Giovanni DD, Gaillard MI, Preciado MV. Pediatric inborn errors of immunity causing hemophagocytic lymphohistiocytosis: Case report and review of the literature. J Leukoc Biol 2022; 112:607-615. [PMID: 35899932 DOI: 10.1002/jlb.5mr0622-037r] [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: 04/12/2022] [Revised: 06/28/2022] [Indexed: 11/07/2022] Open
Abstract
Inborn errors of immunity are a group of genetic disorders caused by mutations that affect the development and/or function of several compartments of the immune system, predisposing patients to infections, autoimmunity, allergy and malignancies. In this regard, mutations that affect proteins involved in trafficking, priming, docking, or membrane fusion will impair the exocytosis of lytic granules of effector NK and cytotoxic T lymphocytes. This may predispose patients to hemophagocytic lymphohistiocytosis, a life-threatening immune disorder characterized by systemic lymphocyte and macrophage activation, and increased levels of cytokines, which lead to an uncontrolled hyperinflammation state and progressive multiorgan damage. In this review, we will describe a clinical case and recent advances in inborn errors of immunity predisposing to hemophagocytic lymphohistiocytosis. Summary sentence: Review of recent advances in inborn errors of immunity predisposing to hemophagocytic lymphohistiocytosis.
Collapse
Affiliation(s)
- María Soledad Caldirola
- Servicio Inmunología, Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP- CONICET-GCBA)- Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| | - Andrea Gómez Raccio
- Servicio de Inmunología, Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| | - Daniela Di Giovanni
- Servicio de Inmunología, Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| | - María Isabel Gaillard
- Servicio Inmunología, Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP- CONICET-GCBA)- Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina.,Sección Citometría - Laboratorio Stamboulian, Buenos Aires, Argentina
| | - María Victoria Preciado
- Laboratorio de Biología Molecular, División Patología, Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP), CONICET-GCBA, Hospital de Niños "Dr. Ricardo Gutiérrez,", Buenos Aires, Argentina
| |
Collapse
|
18
|
He L, Wang Y, Suolitiken D, Zhang R, Liu M, Hua Z, Yao S, Zou H, Wang Z. Outcomes of allogeneic hematopoietic stem cell transplantation for primary hemophagocytic lymphohistiocytosis in adults. Hematol Oncol 2022; 40:390-399. [PMID: 35526261 DOI: 10.1002/hon.3014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Lingbo He
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Yini Wang
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
- Department of General Practice Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Dina Suolitiken
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Ruoxi Zhang
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Menghan Liu
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Zhengjie Hua
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Shuyan Yao
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Heshan Zou
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| | - Zhao Wang
- Department of Hematology Beijing Friendship Hospital Capital Medical University Beijing China100050
| |
Collapse
|
19
|
Allogeneic hematopoietic stem cell transplantation for adult HLH: a retrospective study by the chronic malignancies and inborn errors working parties of EBMT. Bone Marrow Transplant 2022; 57:817-823. [PMID: 35332305 DOI: 10.1038/s41409-022-01634-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 01/20/2022] [Accepted: 03/02/2022] [Indexed: 12/14/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH; hemophagocytic syndrome) is a rare syndrome of potentially fatal, uncontrolled hyperinflammation. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is indicated in primary, recurrent or progressive HLH, but information about its outcomes in the adult population is limited. We obtained data about 87 adult (≥18 years of age) patients retrospectively reported to the EBMT. The median survival time was 13.9 months. The three and five-year overall survival (OS) was 44% (95% CI 33-54%). Among 39 patients with a follow-up longer than 15 months, only three died. Relapse rate was 21% (95% CI 13-30%), while NRM reached 36% (95% CI 25-46%). Younger patients (<30 years of age) had better prognosis, with an OS of 59% (95% CI 45-73%) at three and five years vs 23% (95% CI 8-37%) for older ones. No difference in survival between reduced and myeloablative conditioning was found. To our knowledge, this is the largest report of adult HLH patients who underwent allo-HSCT. Patients who survive the first period after this procedure can expect a long disease-free survival. Both reduced intensity and myeloablative conditioning have therapeutic potential in adult HLH.
Collapse
|
20
|
Cooray S, Sabanathan S, Hacohen Y, Worth A, Eleftheriou D, Hemingway C. Treatment Strategies for Central Nervous System Effects in Primary and Secondary Haemophagocytic Lymphohistiocytosis in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose of Review
This review presents an appraisal of current therapeutic options for the treatment of central nervous system haemophagocytic lymphohistiocytosis (CNS-HLH) in the context of systemic disease, as well as when CNS features occur in isolation. We present the reader with a diagnostic approach to CNS-HLH and commonly used treatment protocols. We discuss and evaluate newer treatments on the horizon.
Recent Findings
Mortality is high in patients who do not undergo HSCT, and while larger studies are required to establish benefit in many treatments, a number of new treatments are currently being evaluated. Alemtuzumab is being used as a first-line treatment for CNS-HLH in a phase I/II multicentre prospective clinical trial as an alternative to traditional HLH-1994 and 2004 protocols. It has also been used successfully as a second-line agent for the treatment of isolated CNS-HLH that is refractory to standard treatment. Ruxolitinib and emapalumab are new immunotherapies that block the Janus kinase—Signal Transducer and Activator of Transcription (JAK-STAT) pathway that have shown efficacy in refractory HLH, including for CNS-HLH disease.
Summary
Treatment of CNS-HLH often requires HLH-94 or 2004 protocols followed by haematopoietic stem cell transplantation (HSCT) to maintain remission, although relapse can occur, particularly with reduced intensity conditioning if donor chimerism falls. CNS features have been shown to improve or stabilise following HSCT in CNS-HLH in the context of systemic disease and in isolated CNS-HLH. Encouraging reports of early cohort studies suggest alemtuzumab and the Janus kinase (JAK) inhibitor ruxolitinib offer potential salvage therapy for relapsed and refractory CNS-HLH. Newer immunotherapies such as tocilizumab and natalizumab have been shown to be beneficial in sporadic cases. CNS-HLH due to primary gene defects may be amenable to gene therapy in the future.
Collapse
|
21
|
Marsh RA, Hebert K, Kim S, Dvorak CC, Aquino VM, Baker KS, Chellapandian D, Saldaña BD, Duncan CN, Eckrich MJ, Georges GE, Olson TS, Pulsipher MA, Shenoy S, Stenger E, Lugt MV, Yu LC, Gennery AR, Eapen M. Comparison of hematopoietic cell transplant conditioning regimens for hemophagocytic lymphohistiocytosis disorders. J Allergy Clin Immunol 2022; 149:1097-1104.e2. [PMID: 34375618 PMCID: PMC8821728 DOI: 10.1016/j.jaci.2021.07.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation for hemophagocytic lymphohistiocytosis (HLH) disorders is associated with substantial morbidity and mortality. OBJECTIVE The effect of conditioning regimen groups of varying intensity on outcomes after transplantation was examined to identify an optimal regimen or regimens for HLH disorders. METHODS We studied 261 patients with HLH disorders transplanted between 2005 and 2018. Risk factors for transplantation outcomes by conditioning regimen groups were studied by Cox regression models. RESULTS Four regimen groups were studied: (1) fludarabine (Flu) and melphalan (Mel) in 123 subjects; (2) Flu, Mel, and thiotepa (TT) in 28 subjects; (3) Flu and busulfan (Bu) in 14 subjects; and (4) Bu and cyclophosphamide (Cy) in 96 subjects. The day 100 incidence of veno-occlusive disease was lower with Flu/Mel (4%) and Flu/Mel/TT (0%) compared to Flu/Bu (14%) and Bu/Cy (22%) (P < .001). The 6-month incidence of viral infections was highest after Flu/Mel (72%) and Flu/Mel/TT (64%) compared to Flu/Bu (39%) and Bu/Cy (38%) (P < .001). Five-year event-free survival (alive and engrafted without additional cell product administration) was lower with Flu/Mel (44%) compared to Flu/Mel/TT (70%), Flu/Bu (79%), and Bu/Cy (61%) (P = .002). The corresponding 5-year overall survival values were 68%, 75%, 86%, and 64%, and did not differ by conditioning regimen (P = .19). Low event-free survival with Flu/Mel is attributed to high graft failure (42%) compared to Flu/Mel/TT (15%), Flu/Bu (7%), and Bu/Cy (18%) (P < .001). CONCLUSIONS Given the high rate of graft failure with Flu/Mel and the high rate of veno-occlusive disease with Bu/Cy and Flu/Bu, Flu/Mel/TT may be preferred for HLH disorders. Prospective studies are warranted.
Collapse
Affiliation(s)
- Rebecca A. Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Soyoung Kim
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Christopher C. Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children’s Hospital, San Francisco, CA
| | | | | | - Deepak Chellapandian
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Johns Hopkins All Children’s Hospital, St Petersburg, FL
| | | | | | - Michael J. Eckrich
- Sarah Cannon Pediatric Transplant and Cellular Therapy Program, Methodist Children’s Hospital, San Antonio, TX
| | | | - Timothy S. Olson
- Department of Pediatrics, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Shalini Shenoy
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO
| | | | | | | | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
22
|
Cancio M, Hebert K, Kim S, Aljurf M, Olson T, Anderson E, Burroughs L, Vatsayan A, Myers K, Hashem H, Hanna R, Horn B, Prestidge T, Boelens JJ, Boulad F, Eapen M. Outcomes in Hematopoietic Stem Cell Transplantation for Congenital Amegakaryocytic Thrombocytopenia. Transplant Cell Ther 2022; 28:101.e1-101.e6. [PMID: 34670170 PMCID: PMC8816844 DOI: 10.1016/j.jtct.2021.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/05/2021] [Accepted: 10/10/2021] [Indexed: 02/03/2023]
Abstract
Congenital amegakaryocytic thrombocytopenia (CAMT) is a rare, inherited bone marrow failure syndrome. Hematopoietic stem cell transplantation (HSCT) is considered a curative treatment option, but existing descriptions of patient and transplant characteristics and outcomes after related and unrelated donor HSCT are sparse. We describe outcomes after HSCT for congenital amegakaryocytic thrombocytopenia (CAMT; n = 86) from 2000 to 2018. We conducted an analysis of data collected by the Center for International Blood and Marrow Transplant Research on patients with CAMT receiving therapeutic allogeneic HSCT. The predominant donor type was HLA-matched or mismatched unrelated donors (n = 58, 67%). The remaining included HLA-matched sibling (n = 23, 27%) and HLA-mismatched relative (n = 5, 6%). The predominant graft types were bone marrow (n = 53, 62%) and cord blood (n = 25, 29%). The median age at transplantation was 3 years, with 82 of 86 patients being transplanted aged ≤10 years. The 5-year graft failure-free and overall survival were 83% (95% confidence interval [CI], 74-90) and 86% (95% CI, 78-93), respectively. An examination for risk factors confirmed mortality was higher after HLA-mismatched relative and mismatched unrelated donor HSCT compared to HLA-matched sibling and matched unrelated donor HSCT (hazard ratio 3.52, P = .04; 75% versus 93%). The 1-year incidence of graft failure was 19% after HLA-mismatched HSCT (n = 32) compared to 7% after HLA-matched HSCT (n = 54, P = .15). Day-100 grade II-IV acute graft-versus-host disease was 13%, 26%, and 30% after HLA-matched sibling, HLA-matched and mismatched unrelated donor HSCT. The 5-year incidence of chronic graft-versus-host disease was 33% with 24 of 28 patients having received grafts from HLA-matched (n = 13) and mismatched unrelated (n = 11) donors. Although HLA-matched donors are preferred, HLA-mismatched donors also extend survival for CAMT.
Collapse
Affiliation(s)
- Maria Cancio
- MSK Kids, Stem Cell Transplantation and Cellular Therapy, Memorial Sloan Kettering Cancer Center, New York, NY,Correspondence: Maria Cancio, MD; Memorial Sloan Kettering Cancer Center, 1275 York Ave. New York, NY 10065,
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Soyoung Kim
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Timothy Olson
- Comprehensive Bone Marrow Failure Center, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Lauri Burroughs
- Department of Pediatrics, University of Washington-Seattle Children’s Hospital, Seattle, WA
| | - Anant Vatsayan
- Division of Blood and Marrow Transplantation, Children’s National Health System, Washington, DC
| | - Kasiani Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center
| | - Hasan Hashem
- Department of Pediatrics, Division of Pediatric Hematology Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Rabi Hanna
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children’s, Cleveland, OH
| | - Biljana Horn
- Pediatric Hematology/Oncology, University of Florida, Gainesville, FL
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children’s Hospital, Auckland, New Zealand
| | - Jaap-Jan Boelens
- MSK Kids, Stem Cell Transplantation and Cellular Therapy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Farid Boulad
- MSK Kids, Stem Cell Transplantation and Cellular Therapy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
23
|
Swaminathan VV, Uppuluri R, Meena SK, Varla H, Chandar R, Ramakrishnan B, Jayakumar I, Raj R. Treosulfan-Based Conditioning in Matched Family, Unrelated and Haploidentical Hematopoietic Stem Cell Transplantation for Genetic Hemophagocytic Lymphohistiocytosis: Experience and Outcomes over 10 Years from India. Indian J Hematol Blood Transfus 2022; 38:84-91. [PMID: 35125715 PMCID: PMC8804033 DOI: 10.1007/s12288-021-01422-z] [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: 01/16/2021] [Accepted: 02/24/2021] [Indexed: 01/03/2023] Open
Abstract
We aimed to analyze data in children with primary hemophagocytic lymphohistiocytosis (HLH) who underwent hematopoietic stem cell transplantation (HSCT). We performed a retrospective study where children up to 18 years, with primary HLH and who underwent HSCT from January 2011 to December 2019, were included. Twenty-five children with genetic HLH underwent HSCT, including variants (Griscelli syndrome (GS2) 7, Chediak-Higashi syndrome (CHS) 2, XIAP mutation 2). Donors were matched family 8 (32%), umbilical cord blood unit 3 (12%), matched unrelated 2 (8%), haploidentical HSCT 12 (48%), (TCR alpha/beta depletion 2 and post-transplant cyclophosphamide 10). With treosulfan-based conditioning, engraftment was achieved in 23/25 (92%) transplants (100% in haplo-HSCT), with sustained complete chimerism in 87%. Disease-free survival was noted in 2/3 children with stable mixed chimerism. Graft-versus-host disease (GVHD) of grade I/II was noted in 6 (24%), grade III in 3 (13%); chronic limited skin GVHD in 2 (12%) children. Overall survival was 72% (87.5% in matched donor, 66.7% in the haplo-HSCT), 71% in GS2, 50% in CHS, 100% in XIAP. HSCT is curative in primary HLH with acceptable disease-free survival with mixed chimerism. Haplo-HSCT is a viable option for those without matched family or unrelated donors.
Collapse
Affiliation(s)
- Venkateswaran Vellaichamy Swaminathan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| | - Ramya Uppuluri
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| | - Satish Kumar Meena
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| | - Harika Varla
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| | - Rumesh Chandar
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| | | | - Indira Jayakumar
- Department of Pediatric Critical Care, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| | - Revathi Raj
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, 320, Padma Complex, Anna Salai, Teynampet, Chennai, 600035 India
| |
Collapse
|
24
|
How I Treat: Allogeneic HSCT for adults with Inborn Errors of Immunity. Blood 2021; 138:1666-1676. [PMID: 34077952 DOI: 10.1182/blood.2020008187] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
Inborn Errors of Immunity (IEI) are rare inherited disorders arising from monogenic germline mutations in genes that regulate the immune system. The majority of IEI are Primary Immunodeficiencies characterised by severe infection often associated with autoimmunity, autoinflammation and/or malignancy. Allogeneic hematopoietic stem cell transplant (HSCT) has been the corrective treatment of choice for many IEI presenting with severe disease in early childhood and experience has made this a successful and comparatively safe treatment in affected children. Early HSCT outcomes in adults were poor, resulting in extremely limited use worldwide. This is changing due to a combination of improved IEI diagnosis to inform patient selection, better understanding of the natural history of specific IEI and improvements in transplant practice. Recently published HSCT outcomes for adults with IEI have been comparable with pediatric data, making HSCT an important option for correction of clinically severe IEI in adulthood. Here we discuss our practice for patient selection, timing of HSCT, donor selection and conditioning, peri- and post HSCT management and our approach to long term follow up. We stress the importance of multidisciplinary involvement in the complex decision-making process that we believe is required for successful outcomes in this rapidly emerging area.
Collapse
|
25
|
Im HJ, Kang SH. Treosulfan-Based Conditioning Regimen for Hematopoietic Stem Cell Transplantation in Pediatric Patients with Hemophagocytic Lymphohistiocytosis. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2021. [DOI: 10.15264/cpho.2021.28.1.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ho Joon Im
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
| | - Sung Han Kang
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Garonzi C, Chinello M, Cesaro S. Emapalumab for adult and pediatric patients with hemophagocytic lymphohistiocytosis. Expert Rev Clin Pharmacol 2021; 14:527-534. [PMID: 33686916 DOI: 10.1080/17512433.2021.1901576] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome. Standard treatment is based on immunosuppressive, cytotoxic drugs and hematopoietic stem cell transplantation (HSCT) in primary HLH. Interferon-gamma (IFN-γ) plays a key pathogenic role. Emapalumab, a monoclonal antibody directed against IFN-γ, is the first target therapy approved for primary HLH with refractory, recurrent or progressive disease or intolerance to conventional therapy. AREAS COVERED We reviewed the pharmacological characteristics, safety, efficacy and clinical uses of emapalumab. We summarized the results of current standard treatment based on chemo-immunosuppressive protocols and outlined the alternative options available. EXPERT OPINION Emapalumab is an effective treatment for HLH with a good safety profile. Its efficacy was demonstrated in a phase II/III study on primary HLH pediatric patients with refractory, relapsing HLH or intolerance to first-line treatment. The use of emapalumab allowed most patients to proceed to HSCT, with a high estimated probability of survival 12 months after transplantation. The outcomes in patients who underwent transplantation compare favorably with those reported previously with either myeloablative or reduced-intensity conditioning regimens. The potential role of emapalumab in the treatment of secondary HLH and as a prevention of graft failure after HSCT deserves to be further assessed.
Collapse
Affiliation(s)
- Chiara Garonzi
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Matteo Chinello
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| |
Collapse
|
28
|
Possible roads to improve hemophagocytic lymphohistiocytosis outcome. Blood Adv 2021; 4:6127-6129. [PMID: 33351106 DOI: 10.1182/bloodadvances.2020003263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/05/2020] [Indexed: 11/20/2022] Open
|
29
|
Ehl S, von Bahr Greenwood T, Bergsten E, Fischer A, Henter JI, Hines M, Lehmberg K, Janka G, Moshous D, Nichols KE. Is neutralization of IFN-γ sufficient to control inflammation in HLH? Pediatr Blood Cancer 2021; 68:e28886. [PMID: 33405364 DOI: 10.1002/pbc.28886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Pediatrics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tatiana von Bahr Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Pediatric Oncology, Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Bergsten
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Alain Fischer
- Imagine Institute, Paris, France.,Paediatric Immunology, Haematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Collège de France, Paris, France
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Pediatric Oncology, Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Melissa Hines
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kai Lehmberg
- Department of Pediatric Hematology and Oncology, Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gritta Janka
- Clinic of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Despina Moshous
- Paediatric Immunology, Haematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Genome Dynamics in the Immune System, Imagine Institute, Paris, France.,Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| |
Collapse
|
30
|
Merli P, Algeri M, Gaspari S, Locatelli F. Novel Therapeutic Approaches to Familial HLH (Emapalumab in FHL). Front Immunol 2020; 11:608492. [PMID: 33424859 PMCID: PMC7793976 DOI: 10.3389/fimmu.2020.608492] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 10/30/2020] [Indexed: 12/18/2022] Open
Abstract
Primary Hemophagocytic lymphohistiocytosis (pHLH) is a rare, life-threatening, hyperinflammatory disorder, characterized by uncontrolled activation of the immune system. Mutations affecting several genes coding for proteins involved in the cytotoxicity machinery of both natural killer (NK) and T cells have been found to be responsible for the development of pHLH. So far, front-line treatment, established on the results of large international trials, is based on the use of glucocorticoids, etoposide ± cyclosporine, followed by allogeneic hematopoietic stem cell transplantation (HSCT), the sole curative treatment for the genetic forms of the disease. However, despite major efforts to improve the outcome of pHLH, many patients still experience unfavorable outcomes, as well as severe toxicities; moreover, treatment-refractory or relapsing disease is a major challenge for pediatricians/hematologists. In this article, we review the epidemiology, etiology and pathophysiology of pHLH, with a particular focus on different cytokines at the origin of the disease. The central role of interferon-γ (IFNγ) in the development and maintenance of hyperinflammation is analyzed. The value of emapalumab, a novel IFNγ-neutralizing monoclonal antibody is discussed. Available data support the use of emapalumab for treatment of pHLH patients with refractory, recurrent or progressive disease, or intolerance to conventional therapy, recently, leading to FDA approval of the drug for these indications. Additional data are needed to define the role of emapalumab in front-line treatment or in combination with other drugs.
Collapse
Affiliation(s)
- Pietro Merli
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Mattia Algeri
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stefania Gaspari
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy.,Department of Maternal, Infantile, and Urological Sciences, Sapienza, University of Rome, Rome, Italy
| |
Collapse
|