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Divyashree K, Singh H, Parkhi M, Karmakar I, Sachdeva MUS, Suri V, Bhalla A. Hemophagocytic Lymphohistiocytosis due to Disseminated Histoplasmosis in a Patient with HIV Infection. J Glob Infect Dis 2023; 15:124-126. [PMID: 37800079 PMCID: PMC10549904 DOI: 10.4103/jgid.jgid_190_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/28/2022] [Accepted: 01/23/2023] [Indexed: 10/07/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis is usually considered a rapidly progressive fatal illness with poor outcomes. It is of two types: primary or familial and secondary. In patients with HIV, opportunistic infections are the secondary triggers of HLH. First line of management of infection associated HLH is treatment of the underlying infection. Here, we present a case of HLH in HIV infection due to disseminated histoplasmosis managed with liposomal amphotericin B, who required immunosuppressive therapy with intravenous immunoglobulin and dexamethasone due to nonresponse to primary therapy.
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Affiliation(s)
- Krishna Divyashree
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harpreet Singh
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mayur Parkhi
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Indrani Karmakar
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Tabaja H, Kanj A, El Zein S, Comba IY, Chehab O, Mahmood M. A Review of Hemophagocytic Lymphohistiocytosis in Patients With HIV. Open Forum Infect Dis 2022; 9:ofac071. [PMID: 35308483 PMCID: PMC8926004 DOI: 10.1093/ofid/ofac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/10/2022] [Indexed: 11/23/2022] Open
Abstract
We provide an elaborate review of cases published between January 2005 and April 2021 on hemophagocytic lymphohistiocytosis (HLH) in HIV patients. Seventy articles describing 81 adult patients (age ≥19 years) were included. The median age was 40 years, and 78% were males. Only 65% were known to have HIV before presentation. CD4 count was ≥200 cells/mm3 in 23%, and HIV viral load was <200 copies/mL in 41%. The lack of meticulous reporting of ≥5 of 8 criteria for HLH diagnosis was evident in a third of cases. At least 1 infectious agent-other than HIV-was believed to trigger HLH in 78% of patients. The most common were Epstein-Barr virus (26%), human herpesvirus 8 (21%), and Histoplasma capsulatum (17%). Sixty percent survived. Among those, 93% received treatment for identified secondary trigger(s), while 51% received HLH-directed therapy. There was significant heterogeneity in the treatment regimens used for HLH.
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Affiliation(s)
- Hussam Tabaja
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Amjad Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Said El Zein
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Isin Yagmur Comba
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Chehab
- Division of Internal Medicine, John Hopkins, Baltimore, Maryland, USA
| | - Maryam Mahmood
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Jariwal R, Jaber FS, Ipalawatte H, Petersen G. An Unusual Case of Hemophagocytic Lymphohistiocytosis Presentation in Acute Human Immunodeficiency Virus. J Investig Med High Impact Case Rep 2021; 9:23247096211021696. [PMID: 34078147 PMCID: PMC8182299 DOI: 10.1177/23247096211021696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) in acute human immunodeficiency virus (HIV) patients has been scarcely reported in the English literature. To the best of our knowledge, only 12 cases have been described. We present a case of a 27-year-old male with no past medical history who was admitted with a new-onset headache, fever, night sweats, and chills. Further laboratory tests revealed transaminitis, leukopenia, thrombocytopenia, positive HIV antigen/antibody test, and markedly elevated ferritin levels, which promoted our suspicion of HLH. This case demonstrates HLH as an unusual presentation of HIV during its seroconversion stage. This report adds a rare disease process to the available literature, and we emphasize that markedly elevated ferritin levels in acute HIV patients should raise suspicion toward a diagnosis of HLH.
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A Case of Hemophagocytic Lymphohistiocytosis Secondary to Disseminated Histoplasmosis. Case Reports Hepatol 2020; 2020:6901514. [PMID: 32884850 PMCID: PMC7455843 DOI: 10.1155/2020/6901514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/14/2020] [Indexed: 11/23/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare condition characterized by a pathologic immune dysregulation resulting in extreme inflammation. Clinical manifestations are varied but can include severe multiorgan failure and death. HLH has been associated with malignancies, autoimmune diseases, and infections, such as histoplasmosis. Histoplasmosis commonly has subclinical manifestations but can also present in its disseminated form. We present the case of an immunocompromised patient with worsening liver function caused by hepatic histoplasmosis that later triggered HLH with severe multiorgan dysfunction.
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Histoplasmosis-Associated Hemophagocytic Lymphohistiocytosis: A Review of the Literature. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2019; 2019:7107326. [PMID: 31662810 PMCID: PMC6791197 DOI: 10.1155/2019/7107326] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/30/2019] [Indexed: 12/27/2022]
Abstract
Background Histoplasmosis is an endemic fungal disease with diverse clinical presentations. Histoplasmosis-associated hemophagocytic lymphohistiocytosis (HLH) is a rare disorder with limited data regarding treatment and outcome. We described the clinical features, treatment, and outcomes of five patients in our institution with histoplasmosis-associated HLH. This review also summarizes the current literature about presentation, treatment, and outcome of this infection-related HLH entity. Methods We searched the electronic medical records for patients with histoplasmosis-associated HLH at our institution from 1/1/2006 to 9/30/2017. Diagnosis of HLH was confirmed by chart review using the HLH-04 criteria. We also searched the current literature for case reports and case series. Results Five cases of histoplasmosis-associated HLH were included from our institution. All five patients were diagnosed after 2010. The literature review yielded 60 additional cases of histoplasmosis-associated HLH. The most common underlying condition was HIV in 61% of cases. The majority of histoplasmosis patients (81%) were treated with amphotericin B formulations. Documented specific treatments for HLH were as follows: nine patients received steroids only, six patients received intravenous immunoglobulin (IVIG) only, three patients received dexamethasone and etoposide, two patients received etoposide, dexamethasone, and cyclosporine, two patients received steroids and IVIG, and one patient received Anakinra and IVIG. The inpatient case fatality rate was 31% with most of the deaths occurring within two weeks of hospital admission. Conclusions Histoplasmosis-associated HLH among adults is an uncommon but serious complication with high associated mortality. Early antifungal therapy with a lipid formulation amphotericin B is critical. The initiation of immunosuppressive therapy with regimens like HLH-04 in this disease entity should be individualized.
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Bonnet B, Blum L, Charpentier C, Martres P, Ritvo PG, Autran B, Guihot A. Short Communication: Extremely Severe CD4 Lymphopenia During HIV-1 Primary Infection. AIDS Res Hum Retroviruses 2019; 35:930-933. [PMID: 31418284 DOI: 10.1089/aid.2019.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We report the case of a patient with a very profound CD4 T cell lymphopenia <20 cells/mm3 in the context of a primary HIV-1 infection, associated with both delayed HIV-specific antibody and CD8 T cell responses. A long-term immune reconstitution was observed after immediate initiation of antiretroviral therapy.
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Affiliation(s)
- Benjamin Bonnet
- Département d'Immunologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Laurent Blum
- Service de Médecine, Centre Hospitalier René Dubos, Pontoise, France
| | - Charlotte Charpentier
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Pascale Martres
- Centre Hospitalier René Dubos, Laboratoire de Microbiologie, Pontoise, France
| | | | - Brigitte Autran
- Département d'Immunologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
- Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Universités, UPMC Univ Paris 06, Paris, France
- INSERM, U1135, CIMI-Paris, Paris, France
| | - Amélie Guihot
- Département d'Immunologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
- Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Universités, UPMC Univ Paris 06, Paris, France
- INSERM, U1135, CIMI-Paris, Paris, France
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Kim B, Choi YW, Pai H, Kim J. A Case of Human Immunodeficiency Virus -triggered Hemophagocytic Lymphohistocytosis Presenting with Severe Bleeding Tendency. Infect Chemother 2018; 53:802-807. [PMID: 31668025 PMCID: PMC8731258 DOI: 10.3947/ic.2018.0203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/27/2017] [Indexed: 11/24/2022] Open
Abstract
Human immunodeficiency virus (HIV) is one of the less common triggers of secondary hemophagocytic lymphohistiocytosis (HLH) in which coagulation disorder is a frequent manifestation. Here, we present a case of HIV-triggered secondary HLH presenting with severe bleeding tendency and fever. Despite high-dose dexamethasone infusion (10 mg/body surface area/day), progressive disseminated intravascular coagulation and thrombocytopenia resulted in massive hemathochezia: the bleeding episode ceased after endoscopic hemoclipping. After then, he took a highly-active antiretroviral therapy (HAART). Eventually, body temperature and overall laboratory findings normalized in response to HAART. Clinicians should not overlook HIV infection as a possible trigger of secondary HLH. In such cases, HAART is the core treatment.
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Affiliation(s)
- Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yeon Woo Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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Tulloch LG, Younes R, Jeng A. Reactive hemophagocytic syndrome in the setting of acute human immunodeficiency virus 1 infection: case report and review of the literature. Int J STD AIDS 2018; 29:1354-1358. [PMID: 30114998 DOI: 10.1177/0956462418788689] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We report a case of reactive hemophagocytic syndrome (RHS) in the setting of acute human immunodeficiency virus type 1 infection (AHI). In addition, we review 11 previously reported cases of RHS precipitated by AHI and discuss strategies in the diagnosis and management of these overlapping clinical entities.
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Affiliation(s)
- Luis G Tulloch
- 1 UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ramee Younes
- 2 Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Arthur Jeng
- 1 UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,3 Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA, USA
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