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Pernaa N, Vakkuri A, Arvonen M, Kuismin O, Santaniemi W, Glumoff V, Lappi-Blanco E, Lantto U, Okkonen M, Kaikkonen K, Junttila J, Kerkelä R, Åström P, Hautala T. Germline HAVCR2/TIM-3 Checkpoint Inhibitor Receptor Deficiency in Recurrent Autoinflammatory Myocarditis. J Clin Immunol 2024; 44:81. [PMID: 38485795 PMCID: PMC10940375 DOI: 10.1007/s10875-024-01685-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
Myocarditis can be caused by viral infection, drug reaction or general inflammatory condition. To provide understanding on inflammatory myocarditis, we describe clinical, genetic, and immunological properties of a young male patient who suffered from recurrent myocarditis episodes since the age of four years. Electrocardiography, troponin I/T, echocardiography, myocardial magnetic resonance imaging and histological findings were consistent with recurrent myocarditis episodes. Homozygous c.245 A > G p.Tyr82Cys pathogenic variant in Hepatitis A Virus Cellular Receptor 2 (HAVCR2) gene encoding T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3) receptor was found. Peripheral blood mononuclear cells were collected when the patient was asymptomatic; CD4+ and CD8+ T lymphoblasts, CD56+ natural killer cells and CD14+ monocytes were negative for surface TIM-3 expression. In vitro, TLR4 mediated interleukin-1β (IL-1β) response was high after LPS/ATP stimulation. Clinical symptoms responded to IL-1 receptor antagonist anakinra. TIM-3 p.Tyr82Cys CD4+ and CD8+ T cell proliferation in vitro was unrestrained. Findings on IL-2, interferon gamma, regulatory T cells, signal transducer and activator of transcription (STAT) 1, 3 and 4 phosphorylation, and PD-1 and LAG-3 checkpoint inhibitor receptor analyses were comparable to controls. We conclude that TIM-3 deficiency due to homozygous HAVCR2 c.245 A > G p.Tyr82Cys pathogenic variant in the patient described here is associated with autoinflammatory symptoms limited to early onset recurrent febrile myocarditis. Excessive IL-1β production and defective regulation of T cell proliferation may contribute to this clinical condition responsive to anakinra treatment.
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Affiliation(s)
- Nora Pernaa
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
| | - Anni Vakkuri
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
| | - Miika Arvonen
- Department of Pediatrics, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Outi Kuismin
- Department of Clinical Genetics, Oulu University Hospital, Kajaanintie 50, Oulu, 90220, Finland
| | - Wenny Santaniemi
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
| | - Virpi Glumoff
- Medical Research Laboratory Unit, Faculty of Medicine, University of Oulu, Oulu, Finland
| | | | - Ulla Lantto
- Department of Otorhinolaryngology-Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
| | - Marjo Okkonen
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
| | - Kari Kaikkonen
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
| | - Juhani Junttila
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
| | - Risto Kerkelä
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
| | - Pirjo Åström
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
| | - Timo Hautala
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, FIN-90014, Finland.
- Infectious Diseases, Oulu University Hospital, Oulu, Finland.
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2
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Dixon KO, Lahore GF, Kuchroo VK. Beyond T cell exhaustion: TIM-3 regulation of myeloid cells. Sci Immunol 2024; 9:eadf2223. [PMID: 38457514 DOI: 10.1126/sciimmunol.adf2223] [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: 07/02/2023] [Accepted: 02/15/2024] [Indexed: 03/10/2024]
Abstract
T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3) is an important immune checkpoint molecule initially identified as a marker of IFN-γ-producing CD4+ and CD8+ T cells. Since then, our understanding of its role in immune responses has significantly expanded. Here, we review emerging evidence demonstrating unexpected roles for TIM-3 as a key regulator of myeloid cell function, in addition to recent work establishing TIM-3 as a delineator of terminal T cell exhaustion, thereby positioning TIM-3 at the interface between fatigued immune responses and reinvigoration. We share our perspective on the antagonism between TIM-3 and T cell stemness, discussing both cell-intrinsic and cell-extrinsic mechanisms underlying this relationship. Looking forward, we discuss approaches to decipher the underlying mechanisms by which TIM-3 regulates stemness, which has remarkable potential for the treatment of cancer, autoimmunity, and autoinflammation.
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Affiliation(s)
- Karen O Dixon
- Gene Lay Institute of Immunology and Inflammation, Brigham and Women's Hospital, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02115, USA
| | - Gonzalo Fernandez Lahore
- Gene Lay Institute of Immunology and Inflammation, Brigham and Women's Hospital, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02115, USA
| | - Vijay K Kuchroo
- Gene Lay Institute of Immunology and Inflammation, Brigham and Women's Hospital, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02115, USA
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3
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Baldrich A, Althaus D, Menter T, Hirsiger JR, Köppen J, Hupfer R, Juskevicius D, Konantz M, Bosch A, Drexler B, Gerull S, Ghosh A, Meyer BJ, Jauch A, Pini K, Poletti F, Berkemeier CM, Heijnen I, Panne I, Cavelti-Weder C, Niess JH, Dixon K, Daikeler T, Hartmann K, Hess C, Halter J, Passweg J, Navarini AA, Yamamoto H, Berger CT, Recher M, Hruz P. Post-transplant Inflammatory Bowel Disease Associated with Donor-Derived TIM-3 Deficiency. J Clin Immunol 2024; 44:63. [PMID: 38363399 PMCID: PMC10873237 DOI: 10.1007/s10875-024-01667-z] [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: 08/21/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
Inflammatory bowel disease (IBD) occurring following allogeneic stem cell transplantation (aSCT) is a very rare condition. The underlying pathogenesis needs to be better defined. There is currently no systematic effort to exclude loss- or gain-of-function mutations in immune-related genes in stem cell donors. This is despite the fact that more than 100 inborn errors of immunity may cause or contribute to IBD. We have molecularly characterized a patient who developed fulminant inflammatory bowel disease following aSCT with stable 100% donor-derived hematopoiesis. A pathogenic c.A291G; p.I97M HAVCR2 mutation encoding the immune checkpoint protein TIM-3 was identified in the patient's blood-derived DNA, while being absent in DNA derived from the skin. TIM-3 expression was much decreased in the patient's serum, and in vitro-activated patient-derived T cells expressed reduced TIM-3 levels. In contrast, T cell-intrinsic CD25 expression and production of inflammatory cytokines were preserved. TIM-3 expression was barely detectable in the immune cells of the patient's intestinal mucosa, while being detected unambiguously in the inflamed and non-inflamed colon from unrelated individuals. In conclusion, we report the first case of acquired, "transplanted" insufficiency of the regulatory TIM-3 checkpoint linked to post-aSCT IBD.
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Affiliation(s)
- Adrian Baldrich
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Dominic Althaus
- Gastroenterology and Hepatology, University Center for Gastrointestinal and Liver Diseases, Clarunis, Basel, Switzerland
| | - Thomas Menter
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Julia R Hirsiger
- Translational Immunology, Department of Biomedicine, University Hospital, Basel, Switzerland
| | - Julius Köppen
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Robin Hupfer
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Darius Juskevicius
- Molecular Diagnostics, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Martina Konantz
- Allergy and Immunity Laboratory, Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Angela Bosch
- Translational Diabetes, Department of Biomedicine, University Hospital, Basel, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Sabine Gerull
- Department of Oncology and Hematology, Kantonsspital Aarau, Aarau, Switzerland
| | - Adhideb Ghosh
- Competence Center for Personalized Medicine, University of Zürich/Eidgenössische Technische Hochschule (ETH), Zurich, Switzerland
| | - Benedikt J Meyer
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Annaise Jauch
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Katia Pini
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Fabio Poletti
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Caroline M Berkemeier
- Division Medical Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Ingmar Heijnen
- Division Medical Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Isabelle Panne
- Gastroenterology and Hepatology, University Center for Gastrointestinal and Liver Diseases, Clarunis, Basel, Switzerland
| | - Claudia Cavelti-Weder
- Translational Diabetes, Department of Biomedicine, University Hospital, Basel, Switzerland
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Jan Hendrik Niess
- Gastroenterology and Hepatology, University Center for Gastrointestinal and Liver Diseases, Clarunis, Basel, Switzerland
| | - Karen Dixon
- Cancer Immunology, Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
- University Center for Immunology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Karin Hartmann
- Allergy and Immunity Laboratory, Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph Hess
- Immunobiology Laboratory, Department of Biomedicine, University Basel Hospital, Basel, Switzerland
- Department of Medicine, Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, UK
- University Center for Immunology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Jörg Halter
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Hiroyuki Yamamoto
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland
- Research Group 2, AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Christoph T Berger
- Translational Immunology, Department of Biomedicine, University Hospital, Basel, Switzerland
- University Center for Immunology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Mike Recher
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel, Basel, Switzerland.
- University Center for Immunology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
| | - Petr Hruz
- Gastroenterology and Hepatology, University Center for Gastrointestinal and Liver Diseases, Clarunis, Basel, Switzerland.
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Song D, Wang J, Zhang J, Hu J, Wu C, Wang Z. Case Report: HAVCR2 mutation-associated Hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1271324. [PMID: 38077348 PMCID: PMC10701531 DOI: 10.3389/fimmu.2023.1271324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
Germline HAVCR2 mutation has been reported to be associated with subcutaneous panniculitis-like T-cell lymphoma (SPTCL) leading to Hemophagocytic lymphohistiocytosis (HLH). Several studies have indicated that HAVCR2 mutation can cause HLH even in the absence of lymphoma, though the exact mechanism remains unclear. In this article, we reported five cases of HAVCR2 mutation-associated HLH. Our analysis revealed an elevated level of IL-1RA in the serum of these patients. Furthermore, we investigated the potential mechanisms underlying HLH associated with HAVCR2 mutation based on changes in cytokine levels. Our findings suggest that HAVCR2 mutation may represent a distinct genetic defect underlying HLH, differing from traditional primary HLH.
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Affiliation(s)
| | | | | | | | | | - Zhao Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
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Moonla C, Polprasert C, Komvilaisak P, Rattanathammethee T, Kongkiatkamon S, Wudhikarn K, Kobbuaklee S, Boonyabaramee P, Tangcheewinsirikul N, Pakakasama S, Rujkijyanont P, Choed-Amphai C, Phuakpet K, Pongudom S, Bunworasate U, Sukswai N, Sosothikul D, Rojnuckarin P. Germline HAVCR2 mutations and their relation to the clinical spectrum of subcutaneous panniculitis-like T-cell lymphoma and hemophagocytic lymphohistiocytosis: results from a multicenter study and meta-analysis. Haematologica 2023; 108:2743-2752. [PMID: 37051767 PMCID: PMC10543163 DOI: 10.3324/haematol.2022.282419] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/05/2023] [Indexed: 04/14/2023] Open
Abstract
Germline HAVCR2 mutations are frequently detected in subcutaneous panniculitis-like T-cell lymphoma (SPTCL) patients with/without hemophagocytic lymphohistiocytosis (HLH) but factors associated with variable manifestations remain undetermined. To evaluate clinical variations and associated factors in SPTCL and/or HLH with/without HAVCR2 mutations, we performed direct sequencing of HAVCR2 exon 2 using DNA from patients with SPTCL or idiopathic HLH/HLH-like systemic illnesses, defined by HLH alone without secondary causes. The systematic review and individual patient data (IPD) level meta-analysis which included the present and previously published studies reporting HAVCR2 mutations in SPTCL with/without HLH populations was subsequently conducted using random-effects meta-analysis and multivariate logistic regression. Among 34 patients enrolled, ten of 28 SPTCL patients developed HLH/HLH-like systemic illnesses. Six cases with HAVCR2Y82C mutation manifested with HLH without panniculitis. Male sex (P=0.03) and age <18 years (P=0.04) were associated with HLH, corresponding to the inverse correlation between age and HLH-2004 score (r=-0.40; P=0.02). Homozygous HAVCR2Y82C mutation was more common in the presence of HLH compared with the absence (75.0% vs. 44.4%; P=0.02). Using IPD from the present and the other three eligible cohorts (N=127), male sex, heterozygous and homozygous/compound heterozygous HAVCR2 mutations were associated with HLH by the adjusted odds ratio of 2.93 (95% confidence interval [CI]: 1.22-7.06), 4.77 (95% CI: 1.05-21.63) and 8.48 (95% CI: 2.98-24.10), respectively. Patients with male sex and/or germline HAVCR2 mutations showed an increased risk of developing HLH. Younger patients tended to manifest with HLH, while older patients typically presented with SPTCL with less frequent HLH/HLH-like systemic illnesses.
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Affiliation(s)
- Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chantana Polprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Patcharee Komvilaisak
- Division of Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Sunisa Kongkiatkamon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kitsada Wudhikarn
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sirorat Kobbuaklee
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pitchayut Boonyabaramee
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nuanrat Tangcheewinsirikul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Samart Pakakasama
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piya Rujkijyanont
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Chane Choed-Amphai
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kamon Phuakpet
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Saranya Pongudom
- Department of Medicine, Udon Thani Medical Education Center, Udon Thani Hospital, Udon Thani, Thailand
| | - Udomsak Bunworasate
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Narittee Sukswai
- Department of Pathology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Darintr Sosothikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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6
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Boonyabaramee P, Polprasert C, Kobbuaklee S, Settapiboon R, Pongudom S, Faknuam S, Kongkiatkamon S, Wudhikarn K, Rojnuckarin P. Good prognosis of adult hemophagocytic lymphohistiocytosis associated with the germline HAVCR2 mutation. Exp Hematol 2023; 125-126:20-24.e4. [PMID: 37479109 DOI: 10.1016/j.exphem.2023.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) in adults may be idiopathic or secondary to various conditions. Recent studies identified germline hepatitis A virus-cellular receptor 2 (HAVCR2) mutations in subcutaneous panniculitis-like T-cell lymphoma (SPTCL) with HLH. The roles of this mutation in HLH, especially in idiopathic group, have never been explored. Of the 65 HLH cases, we detected germline HAVCR2Y82C mutations in nine (13.8%) cases (five SPTCL and four idiopathic HLH). Other causes of HLH were hematologic malignancies excluding SPTCL (32.3%), idiopathic HLH without HAVCR2 mutation (29.2%), infections (15.3%), and autoimmune diseases (9.2%). Germline HAVCR2 mutation was significantly associated with less anemia and better survival. This defines a distinct subgroup of HLH.
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Affiliation(s)
- Pitchayut Boonyabaramee
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chantana Polprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Sirorat Kobbuaklee
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rung Settapiboon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saranya Pongudom
- Department of Medicine, Udon Thani Medical Education Center, Udon Thani Hospital, Udon Thani, Thailand
| | - Saruta Faknuam
- Department of Medicine, Nakhon Pathom Hospital, Nakhon Pathom, Thailand
| | - Sunisa Kongkiatkamon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kitsada Wudhikarn
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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